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East of England Trauma Network TEMPO Trauma East Manual of Procedures and Operations TEMPO November 2012 Welcome to TEMPO Major trauma is the leading cause of death in those aged under 40 and survival rates vary significantly between hospitals (National Audit Office, 2010). We must change this. The Trauma East Manual of Operations and Procedures (TEMPO) aims to provide all those involved in the care of major trauma patients in the east of England with additional information and guidance that will improve the care they give. Based on the successful Ministry of Defence Clinical Guidelines for Operations, it adds to our existing knowledge by highlighting areas that are new or need emphasising within our trauma network. It doesn’t aim to replace any of the many comprehensive books, but complements them instead. Through standardising much of the journey of the trauma patient TEMPO helps us all as we move around the region and easily forms the foundation of teaching across the network. It is designed as a quick reference tool that is easily used, and through its use we will develop it further. This version of TEMPO has involved hundreds of clinicians, managers and commissioners across the region to whom we are very grateful. Their expertise and enthusiasm has motivated us all. This is not the final version! More pages are currently in development and editing to fill some of those empty sections, and it will be updated through the year. As we all use TEMPO in this first year, we will learn what TEMPO should look like in the future in order for it to be of most use. Your thoughts and comments will be collected by your Trauma Committee and a regional group will design version two for Summer 2013. It remains only to thank all those involved in producing TEMPO and we hope that it helps in improving care of our major trauma patients. More information and electronic copies of TEMPO are on our website at www.eoetraumanetwork.nhs.uk Simon Lewis Clinical Lead Major trauma Kate McGlashan Rehabilitation Lead Ruth Derrett Programme Director East of England Trauma Network TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Authors Dr Ademokun, Consultant Haematologist, Ipswich Hosptial Dr Judith Allanson, Evelyn Trust Consultant in Neurorehabilitation, Cambridgeshire Community Services Dr Clive Bezzina, Specialist Registrar in Rehabilitation Medicine Mr Bose, Consultant in Emergency Medicine, Ipswich Hospital Ms Mita Brambhatt, former Network Manager, EoE Trauma Network Dr Rowan Burnstein, Director of Neurocritical Care Unit, Cambridge University Hospitals Dr Pam Chrispin, Medical Director, East of England Ambulance Service Mr Daniel Cody, Critical Care Paramedic, East of England Ambulance Service Dr Clare Cousins, Consultant Radiologist, Cambridge University Hospitals Linda Crawford, Consultant Clinical Psychologist, Fen House, Ely (Brain injury Rehabilitation Trust) Mr David Cumming, Consultant in Orthopaedics, Ipswich Hospital Mr Ben Davis, Consultant in Orthopaedics, Norfolk and Norwich University Hospital Mrs Ruth Derrett, Programme Director, EoE Trauma Network Ms Erica Everitt, Tracheostomy support practitioner, Norfolk and Norwich University Hospitals Dr Sue Freeman, Consultant Radiologist, Cambridge University Hospitals Mr Moheb Gaid, Consultant in Rehabilitation Medicine, Colman Centre for Specialist Rehabilitation Dr Pawan Gupta, Consultant in Emergency Medicine, East and North Hertfordshire Dr David Hodgkinson, Consultant in Emergency Medicine, Ipswich Hospital Mr Peter Hutchinson, Consultant Neurosurgoen, Cambridge University Hospitals Dr Stephen Kirker, Consultant in Rehabilitation Medicine, Cambridge University Hospitals Dr Rob Lewis, Consultant in Intensive Care, Ipswich Hospital Dr Simon Lewis, Clinical Lead, EoE Trauma Network Ms Assiah Mahmood, Clinical Governance Manager, EoE Trauma Network Dr Rob Major, Consultant in Emergency Medicine, Cambridge University Hospitals Dr Roderick Mackenzie, Clinical Director Major Trauma Services, Cambridge University Hospitals Dr Kate McGlashan, Clinical Lead for Trauma Rehabilitation, EoE Trauma Network Ms Claudia Russell, Consultant Nurse Specialist in Tracheostomy Care, Cambridge University Hospitals Mr Simon Standen, Charge Nurse, Emergency Department, Cambridge University Hospitals Dr Alistair Steel, Consultant Anaesthetist, Queen Elizabeth Hospital, Kings Lynn Dr Ali Tompkins, Consultant in Emergency Medicine, Cambridge University Hospitals Dr Catriona Thompson, Consultant in Emergency Medicine, Peterborough and Stamford Hospitals Dr Sara Upponi, Consultant Radiologist, Cambridge University Hospitals Dr Andrew Winterbottom, Consultant Radiologist, Cambridge University Hospitals Mr Martin Wood, Consultant in Orthopaedics, West Suffolk Hospital Helen Young, Trauma Rehabilitation Co-ordinator, EoE Trauma Network Acknowledgements Accenture PACS Connect Team Bedfordshire Acquired Brain Injury Team East of England Regional Transfusion Committee London Spinal Cord Injury Centre, Stanmore Magpas Helimedix National Spinal Injuries Centre, Stoke Mandeville Princess Royal Spinal Injuries Centre, Sheffield All clinicians, management and commissioners who have helped to develop the pathways and care for major trauma patients as part of the Trauma Network Design & production Media Studio, Cambridge University Hospitals NHS Foundation Trust • 01223 216349 MS120302 © NHS East of England Trauma Network 2012 Major trauma TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Contents • 02 • 01 How to use TEMPO Record of amendments •The East of England Trauma Network 03 a. Trauma Network management b. Trauma Network Office (TNO) c. Trauma Network Co-ordination Service (NCS) d. Major trauma pathway i. 45 minute map ii. Patient pathway e. Pre-hospital care f. Major Trauma Centre (MTC) g. Trauma Units (TU) h. Trauma Audit & Research Network (TARN) i.Rehabilitation j. Neighbouring networks k. Trauma contacts L. Trauma Committees m. Trauma governance and incident reporting n.Training •Pre-hospital 04 a. Care on scene b. Trauma triage tool c. Pre-alerting the hospital • 05 Acute care a. Trauma team roles b. Trauma team activation c. ‘Right turn’ resuscitation d. First hour of care in the ED (damage control resuscitation) e. Emergency radiology i. CT ii. MRI iii. Cystourethrogram iv. Interventional radiology (IR) v. Image transfer vi. Plain imaging and FAST f. Emergency transfer g. Trauma team debrief TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network • 06 Emergency treatment guidelines a. Traumatic cardiac arrest i. Emergency thoracotomy b. Catastrophic haemorrhage i. Use of Celox™/ haemostatic ii. Use of tourniquets iii. Use of tranexamic acid (TXA) iv. Massive blood loss protocol v. Use of recombinant factor VIIa c. Airway compromise i. Surgical airway d. Cervical spine trauma i. Immobilisation ii. Spinal clearance e. Breathing problems i. Open pneumothorax ii. Flail chest iii. Thoracostomies f. Circulation problems i. Hypovolaemic shock ii. Neurogenic shock iii. Pelvic trauma iv. Massive facial trauma g.Disability i. Head injury ii. Spinal cord injury h. Environmental injury i. Burns ii. Near drowning iii. Electrical injury iv. Ballistic injuries v. Blast injuries i. Obstetric trauma j. End of life care and organ donation pathway •Paediatrics 07 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network •Rehabilitation 08 a. Goal setting b. Mental capacity act c. Traumatic brain injury i. Pathway ii. Post traumatic seizures iii. Autonomic storming (PAID) iv. Disorders of consciousness (DOC) v. Mood and cognition assessment vi. Behavioural management guidelines d. Spinal cord injury i. Pathway ii. Autonomic dysreflexia (AD) iii. Management of the neuropathic bladder iv. Management of the neuropathic bowel v. Skin care e. Pelvic injury i. Pathway ii. Pelvic and acetabular injuries f. Traumatic limb loss i. Pathway g.Complex orthopaedic injury h. Tracheostomy care i. Burns injury i. Pathway ii. Burns rehabilitation guidance j. Spasticity management guidance k. Augmented nutrition L. Paediatric guidance • Major incidents – emergency preparedness 10 •Toolbox 09 a.Checklists i. Trauma team checklist ii. Trauma team roles b.Burns i. Rule of Nines ii. Lund and Browder chart iii. Burns calculator c. Glasgow Coma Scale (GCS) d. JFK coma scale e. Autonomic dysreflexia monitoring tool f. APC image transfer TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network •Formulary 11 a. Tranexamic acid (TXA) b.Co-amoxiclav c. Recombinant factor VIIa d. Transfer infusions i. Propofol 2% ii. Fentanyl iii. Noradrenaline •Policies 12 a. Patient flow agreement b. NCS advice c. Clinical quality measures •Documentation 13 a. Emergency department trauma documentation b. Rehab prescription proforma and transfer of care record c.TPMS • 14 Audit and feedback a.Audit b. Red card feedback TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 01 How to use TEMPO 01 01 • How to use TEMPO The Trauma East Manual of Operations and Procedures (TEMPO) describes the approved processes, pathways and management of patients with suspected major trauma in the east of England. TEMPO is intended for use by clinicians and those involved in the care of major trauma patients and aims to reflect current best practice. Devised by clinicians throughout the region, and using the concept of the Clinical Guidelines for Operations from the Ministry of Defence, this manual defines standards of care and pathways aimed at reducing morbidity and mortality, and helping patients survive major trauma. The icons below are used throughout to help identify either medical roles or important information. Medical icons The following icons are used to indicate the practitioner that the guidance applies to: Doctor Nurse Ambulance Therapist Instructional icons The following icons are used to indicate instruction points: Monitor Treatment Information icons These are used to indicate important information or other sources: ‘Download’ indicates documents that are available from the Trauma Network website for individual download. ‘Audit’ indicates a network standard that could be audited. Communication Information Download TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Audit 01 Time is important and the icon is used as an indicator of time from a specific point, eg. arrival in the emergency department (ED). The icon below would indicate ‘15 minutes after arrival in the ED’. 01 Arrive ED Document navigation Navigation is used for cross-referencing within the manual using the colour and number of each section. > Section 14.b Red card feedback Review TEMPO will be reviewed at least annually by the Trauma Network. If important amendments are needed between reviews these will be issued as ‘amendments’ on both the website and as hard copy. If you feel amendments would be useful, please discuss at your Trauma Committee meeting and the Chairperson can complete a ‘red card’ (Section 14.b). TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 02 Record of amendments 02 02 • Record of amendments In order to ensure TEMPO is as current as possible, the Trauma Network will need to issue amendments for those with a printed copy. Please ensure you note the change here and replace or insert the pages. For those with an electronic copy, details of amendments are published on our website. Any enquires can be made to the Trauma Network Office. Change number Date of insertion Inserted by DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 02 02 • Record of amendments Change number Date of insertion Inserted by DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY 02 DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY DD/MM/YYYY TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 The East of England Trauma Network 03 03 • The East of England Trauma Network The inclusive Network aims to reduce morbidity and mortality from major trauma. From prevention through to rehabilitation, the Network brings together all involved in the care of the major trauma patient to create a system pathway that aims to meet the need of the patient throughout and realise an expected reduction in mortality of 15–20% over 5–10 years. The Network covers the geographical area of the counties of Cambridgeshire, Bedfordshire, Essex, Hertfordshire, Norfolk and Suffolk and is responsible for the care of major trauma patients within this area. NORFOLK The Queen Elizabeth Hospital Norfolk and Norwich University Hospital James Paget University Hospitals Peterborough City Hospital CAMBRIDGESHIRE Hinchingbrooke Hospital Cambridge University Hospitals SUFFOLK West Suffolk Hospital Bedford Hospital The Ipswich Hospital BEDFORDSHIRE Lister Hospital Luton & Dunstable Hospital Colchester Hospital Queen Elizabeth II Hospital HERTFORDSHIRE West Herts Hospitals ESSEX Princess Alexandra Hospital Chase Farm Hospital Basildon and Thurrock University Hospitals Barnet Hospital North Middlesex University Hospital Cassel Hospital Northwick Park Hospital Hillingdon Hospital Central Middlesex Hospital Broomfield Mid Essex Hospitals Finchley Memorial Hospital Homerton University Hospital The Whittington Hospital Whipps Cross University Hospital Queen's Hospital, Romford LONDON Camden Hospital Newham University Hospital, Plaistow The London Royal Hospital Saint Mary's Hospital Ealing Hospital The Gordon Hospital West Middlesex University Hospital Charing Cross Chelsea and Queen Elizabeth Hospital Woolwich Westminister Hospital Hospital University Hospital Lewisham St George's Hospital King's College Hospital Cassel Hospital Queen Mary's Hospital Croydon University Hospital Surbiton Hospital St Helier Hospital The Priory Hospital www.eoetraumanetwork.nhs.uk TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Southend Hospital 03 03 • The East of England Trauma Network 03.a • Trauma Network management The Network is managed by the Integrated Trauma System Project Board (ITSPB) hosted by the Midlands and East Specialised Commissioning Group. This mix of clinicians, commissioners and patient representatives is responsible for all aspects of care for the most severely injured patients in the East of England Trauma Network. EOE Specialised Commissioning Group Integrated Trauma System Project Board Catherine O’Connell Commissioning Chair Integrated Trauma System Project Board Chief Operating Officer (Interim) NHS Midlands & East Specialised Commissioning Group Dr Simon Lewis Clinical Lead East of England Integrated Major Trauma System Dr Kate McGlashan Rehabilitation Lead East of England Integrated Major Trauma System Ruth Derrett Major Trauma Programme Director Pre-hospital care Acute care Network Dr Pam Chrispin Dr Alistair Steel Dr Sue Robinson Dr Rod Mackenzie Dr Simon Lewis Ongoing care & reconstruction Mr Martin Wood Rehabilitation Prof John Pickard Dr Kate McGlashan TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 03 • The East of England Trauma Network 03.b • Trauma Network Office (TNO) The TNO works closely with commissioners, clinicians and managers to support organisations and service providers within, and associated with, the Integrated Trauma System. It provides the following services: • Network reports • contracting support • performance management • TARN Quality Improvement Programme • Trauma Patient Management System support • Rehabilitation Prescription advice • Directory of Trauma Services • Information Governance support Trauma Network Office Lockton House Clarendon Road Cambridge CB2 8FH • Network Board and Trauma Committee support • TEMPO Clinical Governance Manager Assiah Mahmood [email protected] Network Rehabilitation Co-ordinator Helen Young [email protected] Major Trauma Network Clinical Lead Dr Simon Lewis [email protected] Trauma Rehabilitation Clinical Lead Dr Kate McGlashan [email protected] Network Manager Network Administrator TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Tel: 01223 725355 01223 725361 Safehaven fax: 01223 725591 Confidential email: [email protected] 03 03 • The East of England Trauma Network 03.c • Trauma Network Co-ordination Service (NCS) The Network Co-ordination Service (NCS) aims to streamline referrals, provide decision support, track patient journeys and improve the tempo of decision making. Please note that all calls are recorded Tel: 0300 330 3999 Please contact the NCS 24-hours-a-day for: • highlighting suspected major trauma patients in the pre-hospital phase •pre-alerting any emergency department (ED) about a candidate major trauma patient (triage tool positive) > Section 4.b Trauma triage tool •clinical decision support regarding clinical care and transfer decision making for trauma patients who arrive in an east of England emergency department • requesting transfer or specialist referral for any trauma patient •contacting the Trauma Network rehabilitation co-ordinator (Monday to Friday 09:00 to 17:30 •arranging the transfer of any trauma patient from outside the east of England who requires transfer back into an east of England hospital When you call the NCS on 0300 330 3999, the phone is initially answered by an auto-agent who will guide you through the options. An NCS call-handler will then ask a series of questions related to your call. For ambulance and other pre-hospital personnel pre-alerting an ED, be prepared to provide: • your call-sign Please provide feedback to: Trauma Network Co-ordination Service Box 999 Cambridge University Hospitals Hills Road Cambridge CB2 0QQ Tel: 0300 330 3999 • the approximate age of the patient • the gender of the patient • the destination emergency department (ED) No other details are required. The NCS staff will then transfer your call as quickly as possible to the destination ED red-phone and you should be prepared to provide the ATMISTER pre-alert at that stage. Please note that all calls are timed and recorded. > Section 4.c Pre-alerting the hospital For control room or critical care desk staff notifying NCS of a trauma triage tool result, please be prepared to provide: • the incident CAD reference number • the incident origin time • the incident location • the MPDS code • the call-sign of the crew at the scene • the approximate age of the patient • the gender of the patient • the name of the patient if known • whether an enhanced care team (ECT) has been deployed (and which one) • the likely destination emergency department (ED) For hospital personnel requesting patient transfer or clinical advice, the call will be transferred to the duty NCS consultant. Please be prepared to discuss your case and have to hand the notes and any relevant results from investigations. Please also ensure that: • the responsible consultant in the trauma unit (TU) is aware of the transfer request • that all images have been transferred on the image link system (all CT and plain films) • any radiographic reports have been printed and can be e-mailed, faxed or otherwise transferred on request TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network > Section 10.f APC image transfer 03 03 • The East of England Trauma Network 03.d.i • Major trauma pathway – 45 minute map NORFOLK The Queen Elizabeth Hospital Norfolk and Norwich University Hospital James Paget University Hospitals Peterborough City Hospital 03 CAMBRIDGESHIRE Hinchingbrooke Hospital SUFFOLK West Suffolk Hospital Bedford Hospital Cambridge University Hospitals Major Trauma Centre (MTC) BEDFORDSHIRE The Ipswich Hospital Lister Hospital Luton & Dunstable Hospital Colchester Hospital Queen Elizabeth II Hospital HERTFORDSHIRE West Herts Hospitals ESSEX Princess Alexandra Hospital Chase Farm Hospital Basildon and Thurrock University Hospitals Barnet Hospital North Middlesex University Hospital Cassel Hospital Northwick Park Hospital Hillingdon Hospital Central Middlesex Hospital Broomfield Mid Essex Hospitals Finchley Memorial Hospital Homerton University Hospital The Whittington Hospital Whipps Cross University Hospital Queen's Hospital, Romford LONDON Camden Hospital Southend Hospital Newham University Hospital, Plaistow The London Royal Hospital Saint Mary's Hospital Ealing Hospital The Gordon Hospital West Middlesex University Hospital Charing Cross Chelsea and Queen Elizabeth Hospital Woolwich Westminister Hospital Hospital University Hospital Lewisham St George's Hospital King's College Hospital Cassel Hospital Queen Mary's Hospital Croydon University Hospital Surbiton Hospital St Helier Hospital The Priory Hospital 45 minute journey time by land to MTC (peak hours: 07:00–09:00 and 16:00–19:00) 45 minute journey time by land to MTC (off-peak hours) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 • The East of England Trauma Network 03.d.ii • Major trauma patient pathway 999 call Key: Reception, resuscitation and emergency care NCS Community service/home Specialist hospital Acute care, reconstruction and rehabilitation Section 08 Level 0–1 care Level 1–2 care Level 3 care Section 05 Interventional radiology Inpatient area Operating theatre Acute hospital Section 04 No transfer Transfer to specialist trauma unit Transfer to MTC Rehabilitation NCS Acute care Major Trauma Centre (MTC) NCS Pre-hospital response NCS CT Pre-hospital care Major trauma positive <45 mins Triage tool positive >45 mins Trauma unit (TU) Network Co-ordination Service Emergency Department (ED) Pre-hospital care outreach support NCS 03 TEMPO Major trauma event TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 • The East of England Trauma Network 03.e • Pre-hospital care Pre-hospital care is provided by: • East of England Ambulance Service NHS Trust The primary responder to all 999 calls involving major trauma in the east. Contact: Dr Pam Chrispin, Medical Director – Tel: 0845 6013733 www.eastamb.nhs.uk – B asics Essex Accident and Rescue Service Contact: Mr Paul Gates, Chair – Tel: 01473 218771 www.bearsmedics.org.uk – E ast Anglian Air Ambulance Contact: Mr Tim Page, CEO – Tel: 0845 066 9999 www.eaaa.org.uk – E ssex and Herts Air Ambulance Contact: Ms Jane Gurney, CEO – Tel: 0845 2417 690 www.ehaat.uk.com – Magpas Helimedix Contact: Mr Daryl Brown, CEO – Tel: 01480 371060 www.magpas.org.uk – N orfolk Accident Rescue Service Contact: Mr Marc Godfrey – Tel: 01603 260524 www.nars.uk.com uffolk Accident Rescue Service – S Contact: Dr Jeremy Mauger, Chairman – Tel: 01473 218771 www.sars999.org.uk • Other NHS Ambulance Trusts Both East Midlands and London Ambulance Trusts operate on the borders of our region and may attend patients within the region. www.emas.nhs.uk www.londonambulance.nhs.uk This list does not imply any form of Network approval, nor is it exhaustive. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 03 • The East of England Trauma Network 03.f • Major Trauma Centre (MTC) The East of England Major Trauma Centre (MTC) is located at Cambridge University Hospitals NHS Foundation Trust. The MTC provides all specialist acute services for major trauma patients through an integrated service, which interfaces with all components of the major trauma patient pathway. Patients may be transported directly to the MTC following appropriate application of the pre-hospital care triage tool, or may be transferred following initial care within a designated East of England trauma unit (TU). The MTC, on behalf of the Trauma Network, hosts the Network Co-ordination Service – which has been specifically designed to co-ordinate the care of major trauma patients across the region and provide dedicated clinical decision support and outreach for clinicians caring for, and managing, major trauma patients. Clinical Director, Major Trauma Centre Dr Roderick Mackenzie [email protected] 03 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 • The East of England Trauma Network 03.g • Trauma Units (TU) Trauma units (TU) have a vital role in the initial resuscitation of major trauma patients according to TEMPO. They may also be involved in the ongoing care, specialist trauma areas and rehabilitation. The network has 14 trauma units Basildon and Thurrock University Hospitals NHS Foundation Trust Nethermayne Basildon Essex SS16 5NL Tel: 0845 155 3111 Trauma link: [email protected] Bedford Hospital NHS Trust Kempston Road Bedford MK42 9DJ Tel: 01234 355122 Trauma link: [email protected] Colchester Hospital University NHS Foundation Trust Trust HQ Turner Road Colchester Essex CO4 5JL Tel: 01206 747474 Trauma link: [email protected] East and North Hertfordshire NHS Trust (Lister Hospital only) Lister Hospital Corey’s Mill Lane Stevenage Hertfordshire SG1 4AB Tel: 01438 314333 Trauma link: [email protected] The Ipswich Hospital NHS Trust Heath Road Ipswich Suffolk IP4 5PD Tel: 01473 712233 Trauma link: [email protected] TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 James Paget University Hospitals NHS Foundation Trust Lowestoft Road Gorleston Great Yarmouth Norfolk NR31 6LA Tel: 01493 452452 Trauma link: [email protected] Luton and Dunstable Hospital NHS Foundation Trust Lewsey Road Luton LU4 0DZ Tel: 0845 127 0 127 Trauma link: [email protected] Mid Essex Hospital Services NHS Trust 03 Broomfield Hospital Court Road Chelmsford Essex CM1 7ET Tel: 0844 8220002 Trauma link: [email protected] Norfolk and Norwich University Hospital NHS Foundation Trust Colney Lane Norwich NR4 7UY Tel: 01603 286286 Trauma link: [email protected] Peterborough and Stamford Hospitals NHS Foundation Trust Edith Cavell Hospital Bretton Gate Peterborough PE3 9GZ Tel: 01733 874000 Trauma link: [email protected] Princess Alexandra Hospital NHS Trust Hamstel Road Harlow Essex CM20 1QX Tel: 01279 444455 Trauma link: [email protected] TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network The Queen Elizabeth Hospital King’s Lynn NHS Foundation Trust Gayton Road King’s Lynn Norfolk PE30 4ET Tel: 01553 613613 Trauma link: [email protected] Southend University Hospital NHS Foundation Trust Prittlewell Chase Westcliff-on-Sea Essex SS0 0RY Tel: 01702 435555 Trauma link: [email protected] West Suffolk Hospital NHS Trust Hardwick Lane Bury St Edmunds Suffolk IP33 2QZ Tel: 01284 713000 Trauma link: [email protected] Local emergency hospitals (LEH) Major trauma patients will not be triaged by pre-hospital providers to local emergency hospitals (LEH). These hospitals will continue to receive non-major trauma patients and may have a role in other areas of the major trauma pathway such as rehabilitation. Hinchingbrooke Hospital Hinchingbrooke Park Huntingdon Cambridgeshire PE29 6NT Trauma link: [email protected] QE2 Welwyn Garden City Howlands Welwyn Garden City Hertfordshire AL7 4HQ TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 03 • The East of England Trauma Network 03.i • Rehabilitation Rehabilitation can be defined in many ways, but an approach used by the British Society of Rehabilitation Medicine describes rehabilitation in terms of both a concept and a service as follows: Conceptual definition: A process of active change by which a person who has become disabled acquires the knowledge and skills needed for optimal physical, psychological and social function. Service definition: The use of all means to minimise the impact of disabling conditions and to assist disabled people to achieve their desired level of autonomy and participation in society. These terms can be usefully applied to people who have experienced major trauma. In addition, it needs to be acknowledged that severe injury of an individual affects a wider pool of people both directly and indirectly, and the needs of families and carers should also be addressed during the rehabilitation process. A person sustaining a major trauma will have a multi-disciplinary team (MDT) involved in their rehabilitation pathway. The major trauma rehabilitation pathway means that rehabilitation commences at the earliest point after admission through the emergency department (ED), with a formal assessment resulting in a Rehabilitation Prescription within two working days of resuscitation and stabilisation. Major trauma rehabilitation pathway Major trauma event Admission to Major Trauma Centre (MTC) emergency department, or trauma unit (TU) emergency department From MTC emergency department transferred to neuro critical care unit (NCCU) Transfer from TU emergency department to MTC emergency department if appropriate After liaison with MTC, direct transfer from TU Admission to rapid access acute rehab (RAAR) at MTC Transfer to specialist ward at MTC Transfer to specialist unit (eg. burns, spinal cord injury) Community rehabilitation at home or at longer term specialist placement Outpatient follow-up TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 The Trauma Network will be following patients through the first year of their recovery. This will cover different stages in their rehabilitation pathway as outlined below. Support will be offered to families and carers throughout the pathway. Acute rehabilitation This stage is when the person is being treated in the MTC or other specialist unit, with the emphasis being on managing the original injuries and reducing the impact and likelihood of secondary complications. From a rehabilitation perspective, this would be described as focusing on impairment and secondary complications (pathology), eg. pressure sores, chest infection, malnutrition, contractures etc. The two working days rehabilitation prescription describes the domains addressed in detail. Post-acute rehabilitation This stage describes the period when patients are more medically and surgically stable (ie. out of the critical care/HDU settings) and well enough to actively participate in a rehabilitation programme. Post-acute rehabilitation primarily focuses on regaining mobility and independence in self-care with the aim of enabling the person to manage safely at home. Thus the interventions are aimed at reducing disability through promoting activity and independence. For severely injured individuals, this phase may last many months. For patients unable to actively participate (those with disorders of consciousness or severe behavioural/cognitive disorder) in this phase, a rehabilitation programme is constructed around the patient, in their best interests. 03 Community rehabilitation References Royal College of Physicians and British Society of Rehabilitation Medicine, Rehabilitation following acquired brain injury: national clinical guidelines, (Turner-Stokes L, ed) London: RCP, BSRM (2003) This final phase of rehabilitation is often the most prolonged and is essential to the optimisation of a person’s recovery. The emphasis is on more extended activities of daily living, social integration and return to work or education. Psychological adjustment to the injuries by the person and the impact of carer stress often come to the fore and need addressing. A focus on improving participation and enhancing quality of life is undertaken. All these phases will be monitored by the trauma rehabilitation co-ordinator. Outcome measures one year following the trauma will be collected and audited. National Service Framework for long-term conditions, Department of Health, 2005 Royal College of Physicians, Medical rehabilitation in 2011 and beyond, Report of a working party. London: RCP (2010) British Society of Rehabilitation Medicine, Vocational assessment and rehabilitation for People with Long-Term Neurological Conditions: Recommendations for best practice, BSRM (2010) World Health Organisation International Classification of Functioning, Disability and Health (ICF), WHO, 2001 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 • The East of England Trauma Network 03.j • Neighbouring networks London London Trauma Office London Ambulance Service Headquarters 8–20 Pocock Street London SE1 OBW Contact: London Trauma System Manager Tel: 0207 783 2539 Web:www.londontraumaoffice.nhs.uk East Midlands East Midlands Ambulance Service NHS Trust Beechdale Road Bilborough Nottingham NG8 3LL Contact: Trauma Network Director Tel: 0115 9193482 Web:www.midtrentccn.nhs.uk South central South Central Specialised Commissioning Group Oakley Road Southampton SO16 4GX Tel: Web: 0238 062 7444 www.scscg.nhs.uk TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 03.k • Trauma contacts East of England Trauma Network East of England Trauma Network Contacts Trauma Network Co-ordination (NCS) 0300 330 3999 Trauma call (adult, paediatric, obstetric) Massive blood loss Radiology – CT Theatre Co-ordinator ITU Please complete for your own area. The Trauma Network Office can provide laminated A4 personalised posters on request. 03 • The East of England Trauma Network 03.L • Trauma Committees All Trusts within the Trauma Network must have a focus for the governance of trauma care through a Trauma Committee which meets on a regular basis. It is the focal point for local system development and quality assurance. The Trauma Committee must have good, direct links to the Trust senior management groups and have representation from all those involved in the care of trauma patients. The chair of the Trauma Committee has a seat on the Regional Trauma Chairs Committee hosted and led by the Trauma Network Office (TNO). The TNO aims to support local Trauma Committees and add purpose and focus, whilst assuring quality of care in accordance with network practice. The suggested remit of the Trauma Committee is to: • continuously improve the care given to trauma patients in order to reduce mortality and morbidity • review and critically evaluate the Trusts’ performance from the UK TARN database • establish and support best practice relating to all aspects of trauma care, including the implementation of East of England Trauma Network guidance, policies and best practice protocols • attend the East of England Trauma Chairs meetings and act as single point of contact for the Network (Trauma Chair, or nominated deputy) • organise and provide a comprehensive education programme in trauma care skills, working with the Network where appropriate • ensure adequate resources for trauma care • audit relevant clinical cases, including review of incidents reported through Trusts’ internal clinical governance process • provide comparative statistics to clinicians about institutional performance. • provide summative information to local health commissioners about the trauma workload and its management The Trauma Network recommends that the Trauma Committee should compose of (as a minimum) multidisciplinary representation from: • emergency medicine • trauma and orthopaedics • general surgery •radiology •anaesthetics • intensive care •paediatrics • specialist surgery (if any, or may be more than one) •rehabilitation • transfusion and pathology • Director of Operations (or equivalent) • Director of Commissioning (or equivalent) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 03 The Trauma Committee should meet at least every three months and the agenda should include: • current TARN performance • review of latest TARN report • clinical review of unexpected deaths • clinical review of unexpected survivors • update from the Trauma Network • report on investigations of incidents related to trauma care • items for the Regional Trauma Chairs Meeting Trauma Committee and Chairs Basildon and Thurrock University Hospital NHS Foundation Trust Email: [email protected] Bedford Hospital NHS Trust Email: [email protected] Cambridge University Hospitals NHS Foundation Trust Email: [email protected] Colchester Hospital University NHS Foundation Trust 03 Email: [email protected] East and North Hertfordshire NHS Trust Email: [email protected] Hinchingbrooke Hospital NHS Trust Email: [email protected] Ipswich Hospital NHS Trust Email: [email protected] James Paget University Hospital NHS Foundation Trust Email: [email protected] Luton and Dunstable Hospital NHS Foundation Trust Email: [email protected] Mid Essex Hospital Services NHS Trust Email: [email protected] Norfolk and Norwich University Hospital NHS Foundation Trust Email: [email protected] Peterborough and Stamford Hospitals NHS Foundation Trust Email: [email protected] Princess Alexandra Hospital NHS Trust Email: [email protected] Queen Elizabeth Hospital King’s Lynn NHS Trust Email: [email protected] Southend University Hospital NHS Foundation Trust Email: [email protected] West Suffolk Hospital NHS Trust Email: [email protected] TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Chair: Prof J Pickard Commissioning lead: SCG Rehabilitation Chair: Mr Martin Wood Commissioning lead: SCG Reconstruction and rehabilitation Chair: Dr S Lewis and Dr R Mackenzie Commissioning lead: SCG Network organisation Chair: Dr S Robinson Commissioning lead: SCG Acute care Chair: Dr P Chrispin & Dr A Steel Commissioning lead: SCG This structure will change with the formation of the Network Board in autumn 2012 Acute Trust Trauma Committees Chair: Catherine O’Connell, Chief Operating Officer Clinical leads: Dr Simon Lewis, Network Development Dr Kate McGlashan, Trauma Rehabilitation Executive commissioning lead: Ruth Derrett, Major Trauma Programme Director EoE Trauma Network Board Midlands and East Specialised Commissioning Group Board Pre-hospital care and inter-hospital transfer Network Co-ordination Service Network Transfer Service Rehabilitation Services Ambulance Service Trauma Units Major Trauma Centre Trauma Network Office 03 • The East of England Trauma Network 03.m • Trauma governance 03 03.m • Trauma governance Incident reporting to the Trauma Network Office (TNO) All Trusts within the East of England Trauma Network will continue to operate within their own clinical governance framework and all adverse incidents should be reported in line with their internal governance system. Any adverse incidents occurring during any part of the trauma patient’s pathway should be reported in line with the Trust’s internal process and reviewed at the monthly Trauma Committees. A copy of all reviews should be sent to the TNO clinical governance manager. Along with all operational partners, Trusts and third sector health care providers are required to provide a summary of all of these adverse incidents/risks on a monthly basis to the Trauma Network Office. These can be followed up further by the TNO if required. Reports should be sent to: 03 Clinical Governance Manager Trauma Network Office Lockton House Clarendon Road Cambridge CB2 8FH Tel: 01223 725355 Email: [email protected] TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 04 Pre-hospital 04 04 • Pre-hospital 04.a • Care on scene Ambulance Service staff should apply JRCALC guidelines to major trauma patients. Medical and enhanced care teams (ECT) should be guided by ATLS principles. • All pre-hospital personnel must apply current best-evidence based care, which may at times supersede JRCALC or ATLS guidance. • Assessment and resuscitation may need to be performed concurrently. Minimum monitoring standards Every major trauma patient must have multimodality monitoring applied. Continuously (recorded every 5 minutes) • clinical assessment • pulse oximetry (SpO2) • heart rate (ECG) • respiratory rate • end-tidal capnography (all patients with endotracheal tubes or supraglottic airway devices, whether breathing spontaneously or ventilated) Every 5 minutes • non-invasive blood pressure (NIBP) Every 15 minutes • pain score • pupil size and reactivity Catastrophic haemorrhage • Significant bleeding should be controlled as soon as it is identified, even before management of the airway. > Section 6.b.i > Section 6.b.ii Use of Celox™ Use of tourniquets Airway and breathing support • Apply pulse oximetry as soon as patient contact is made and continuously throughout the pre-hospital phase. • Provide oxygen to all major trauma patients. • Manage hypoxia assertively. Airway support should be applied in a stepwise manner until an open airway is achieved. • Airway manoeuvres should be used and adjuncts inserted if required. • Endotracheal intubation without drugs should only be attempted if there is impending or actual cardiorespiratory arrest. Enhanced care teams should consider the need for securing a definite airway in patients with an inability to protect or maintain an airway or who have a failure to oxygenate or ventilate. Breathing assessment needs to be systematic and thorough looking for evidence of common traumatic injuries (front and back as needed). TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 04 04.a • Care on scene Circulatory support Adequate organ perfusion must be maintained in major trauma patients. However, the need to maintain organ perfusion must be balanced with the risk of exacerbation of bleeding and coagulopathy that may accompany normo- or hypertension. In the first instance intravenous fluids should be used to restore an adequate circulating volume. Boluses of 250mls (for adults) of crystalloid solution should be titrated to effect. The following targets should be used for guidance (adults): • traumatic brain injury – systolic blood pressure >120mmHg • blunt traumatic injuries – systolic blood pressure >80mmHg • penetrating traumatic injuries – systolic blood pressure >60mmHg In the absence of a brain injury, hypotension should be tolerated if it is associated with a clear sensorium (alert and orientated). The presence of a brain injury requires a balance between maintaining cerebral perfusion pressure and not worsening bleeding. Boluses of fluid should be cautiously titrated to maintain adequate organ perfusion. The use of inotropes and vasopressors may improve blood pressure but are associated with worsening outcomes. They should be used with great caution in patients who are no longer fluid responsive. Haemorrhage control • bleeding must be controlled assertively 1. Direct pressure should be applied to open bleeding wounds. 2. For bleeding limbs, consideration should be given to the use of tourniquets, to be applied just above the wound. 04 3. Where direct pressure / tourniquets alone are unable to stop external bleeding haemostatic agents (eg. Celox™) should be applied. 4. Limb fractures should be splinted (and tractioned, if appropriate) to limit the extent of concealed bleeding. Tranexamic acid should be considered for all adult major trauma patients with proven or likely significant haemorrhage. > Section 11.a Tranexamic acid Where a patient is exsanguinating a request for immediate blood availability must be made at the time of the ATMISTER hospital pre-alert. Ask for ‘massive blood loss’ activation. Neurological assessment and support • Vertebral column protection should be applied to all major trauma patients not meeting critera for clearance. Initially this should be by manual in-line stabilisation of the complete (cervical, thoracic and lumber) spine. A cervical collar should be applied but should be loose fitting to minimise rises in intracranial pressure and further injury. Assess neurological function: • Glasgow Coma Score • pupil size and reactivity • limb power • limb sensations (and highest normal dermatome if sensory level present). TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 04.a • Care on scene A Glasgow Coma Score should be calculated, the motor component of which will be required for application of the trauma triage tool – a low motor score (4 or less) identifying likely major trauma. > Section 10.c Glasgow Coma Scale Patients with brain injuries and altered levels of consciousness should have neuroprotective strategies commenced. Consideration should be given to the use of: • anaesthesia (sedation and analgesia) • mechanical ventilation (control of oxygenation and carbon dioxide) • maintenance of adequate cerebral perfusion pressures (MAP > 90mmHg) • optimise cerebral venous drainage (loose collars / ties, head up) • hypertonic solutions Burns Patients with burns should be conveyed to the nearest emergency department (ED). Airway, breathing and circulatory support with analgesia should be provided en-route as necessary. Pain All major trauma patients should be provided with analgesia. • Consider intravenous opioid analgesia for all patients. • Splint fractured limbs. • Entonox should be avoided in patients with chest injuries. • Procedural sedation should be provided prior to performing painful procedures or manoeuvres (eg. limb splinting/extrication). • Regional analgesia using nerve blocks may be useful, particularly for lower limb injuries. • Consider pre-hospital anaesthesia for patients in severe pain for which systemic analgesia is unlikely to be adequate due to extent of injuries. Enhanced care teams (ECT) Enhanced care teams (ECT), consisting of a senior pre-hospital emergency medicine doctor and a critical care paramedic, are active within the region to provide advanced critical care interventions and clinical support. • If a patient has sustained major trauma they should be conveyed according to the Trauma Triage Tool as rapidly as possible. • ECTs can be requested by the attending crew via Ambulance Control. • Delays at scene whilst awaiting an ECT should be avoided. • If necessary the attending crew should make progress towards the Trauma Unit (TU) / Major Trauma Centre (MTC), informing and updating Ambulance Control. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 04 04 • Pre-hospital 04.b • Trauma triage tool Suspected major trauma? Arrival on scene Does injured patient meet any of the criteria below? Physiology Sustained respiratory rate below 10 or above 29? (use JRCALC abnormal paediatric values for children) Sustained systolic BP below 90 mmHg or absent radial pulses? GCS motor score of 4 or less (withdrawal to pain or less)? Anatomy Open pneumothorax or flail chest? Suspected major pelvic fracture? More than one fractured proximal long bone? Crushed, degloved, mangled or amputated limb? Suspected open or depressed skull fracture? YES NO Inform CCD now Channel 202 using ‘Priority RTS’ Inform CCD now Channel 202 using ‘Priority RTS’ and proceed to nearest emergency department Can Major Trauma Centre be reached within 45 minutes? YES Can airway, breathing and bleeding be controlled? NO Consider requesting pre-hospital medical team NO YES Go directly to nearest Major Trauma Centre Pre-alert MTC / ED Call 0300 330 3999 Select Option 1 NCS will put you through to the unit TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Go to nearest Trauma Unit 04.b • Trauma triage tool Enhanced care teams (ECT) The trauma triage tool will be followed by all enhanced care teams. Where a helicopter is used for patient transport, the 45 minutes applies to the total journey time from scene to the MTC emergency department. This includes all associated land ambulance transfers at either end. If the enhanced care team feel there are good clinical grounds for taking the patient to the MTC but they are either not triggering the tool (anatomy or physiology) or are over 45 minutes journey time, they (or their consultant) should discuss decisionmaking early with the duty consultant at Network Co-ordination Service. > Section 03.c Network Co-ordination Service 04 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 04 • Pre-hospital 04.c • Pre-alerting the hospital A Age and sex T Time of incident M Mechanism I Injuries suspected S Signs (observations) T Treatment given E ETA Requests R – obstetric / cardiothoracic 04 – massive blood loss – right turn resuscitation The pre-alert should be given by calling Trauma Network Co-ordination Service and using the ATMISTER mnemonic. It should take only 30 seconds to give an ATMISTER. It should be also used at handover to the trauma team in the ED unless: • CPR is in progress • immediate airway problem • catastrophic haemorrhage in which case clinical care must proceed immediately to address the problem. References Trauma: Who Cares? (NCEPOD, 2007) Regional Networks for Major Trauma (NHS Clinical Advisory Groups Report, 2010) UK Ambulance Service Clinical Practice Guidelines, (Joint Royal College Ambulance Liaison Committee, 2006) Advanced Trauma Life Support (American College of Surgeons) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05 Acute care 05 05 • Acute care > Section 10.a.ii 05.a • Trauma team roles Trauma team roles Airway specialist Airway assistant Nurse 1 Doctor 1 Doctor 2 Nurse 2 05 Trauma team leader TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Scribe 05.a • Trauma team roles Trauma team leader • consultant in MTC • ST5 or above in TU • has East of England trauma team leader training certificate • controls and manages the trauma team resuscitation • makes decisions in conjunction with specialists • prioritises investigations and treatments • is responsible for all handovers and transfers • follows checklist > Section 10.a.i Trauma team checklist Before patient arrival • ensures trauma team activated • appoints scribe (preferably additional team member) • ensures correct PPE and identification worn • ensures CT notified • ensures team members ‘book in’ on ED documentation • introductions and roles assigned • ensures tranexamic acid ready (if needed) • ensures blood products ready (if activated) • ensures theatre ready (if right turn resus) • briefs team • starts the clock when the patient arrives in bay Airway specialist • communicates airway patency and issues to team leader / scribe •ensures patient oxygenated and ventilated with no airway obstruction. Intubate when appropriate only in discussion with the team leader 05 • ensures cervical spine immobilisation •it is usually appropriate for the airway specialist to talk to the patient and provide ongoing assessment of GCS. Reassures patient on arrival, sets the scene of what is happening and takes AMPLE history: Aallergies Mmedications P past medical history L last meal E everything else relevant • this role may be shared with doctor 1. Inform outcome to team leader / scribe • considers need for endogastric tube •arterial lines may be indicated. To avoid delay to CT this can usually be done after CT or in the operating theatre. It should not delay either • communication with theatres role is shared with surgeon TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05.a • Trauma team roles Airway assistant • may assist with removing patient clothes, have scissors to hand •assists airway specialist in all airway interventions • takes emergency airway equipment / drugs on any transfers (CT, theatre, ITU) Doctor 1 •undertakes primary survey <C>ABC. Clearly states findings to team leader and scribe •takes AMPLE history if anaesthetist busy, reassures patient on arrival, sets the scene of what is happening Aallergies Mmedications P past medical history L last meal E everything else relevant •performs procedures depending on skill level and training. Confirms skill levels with team leader prior to patient arriving • neurology exam needed before paralysing anaesthetic agents used • ensures patient kept warm Nurse 1 •prepares for trauma call with warming devices, tranexamic acid (if needed) •prepares for the trauma call with level one run through when indicated, warmed IV fluids run through, chest drain sets out if suggested •ensures full monitoring is applied quickly and observations fed back to the team leader •has scissors ready – removes all clothing including underwear and store securely • covers with Bair Hugger / blankets – check temperature •prepares for transfer to CT ASAP (possibly within 10–20 minutes) and/or theatre • helps with procedures as identified, eg. catheter, chest drain, arterial line Doctor 2 • two peripheral lines taking 20mls of blood at same time • bloods needed will usually include: FBC U&E LFT pregnancy test XM 6 units (or G&S occasionally) glucose coag screen venous gas (will include glucose and lactate) • orders radiology and bloods in discussion with team leader •performs procedures depending on skill level and training and as guided by team leader. Confirms skill levels with team leader prior to patient arriving • FAST scan if accredited and not delay CT • administers drugs, eg. analgesia, antibiotics. Keeps patient warm • undertakes secondary survey including tympanic membranes TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05 05.a • Trauma team roles Nurse 2 •has scissors ready – removes all clothing with nurse 1 •helps with getting IV access and sending bloods off if required, sets up intraosseus kit (ezi-IO) if no / difficult IV access •draws up drugs / administers as prescribed •helps with procedures as identified for nurse 2 or doctor 2 •prepares for transfer to CT as soon as possible and/or theatre Scribe •use ED trauma documentation •records names, grades and specialties of all clinical staff attending, plus time of arrival •ensures clock is started when patient arrives and is recorded in ED trauma documentation • records all observations • records all findings and interventions • ensures patient wrist labels are applied (including allergy) > Section 13.a ED trauma documentation 05 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05 • Acute care 05.b • Trauma team activation On receiving a pre-alert message from a pre-hospital provider, a trauma team should be activated if any of the following criteria are met: Trauma triage tool ‘positive’ Traumatic cardiac arrest A airway obstruction / concern RR <10 or >29 B open pneumothorax flail chest massive / catastrophic haemorrhage SBP <90mmHg (sustained) C suspected major pelvic # penetrating injury to neck / chest GCS motor <4 D evidence of spinal cord injury suspected open / depressed skull # more than 1 proximal long bone # E crushed, degloved, mangled or amputated limb Trauma team activation Tel: When activating the trauma team, it should be clear whether it is ADULT PAEDIATRIC OBSTETRIC TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05 05 • Acute care 05.d • First hour of care in the emergency department The TEMPO guidance aims to build upon the teaching and practice of ATLS (8th edition) which all those involved in acute trauma care should be familiar with and is regarded as the basic standard of care for major trauma patients. All emergency departments in the Network are expected to follow the same emergency management of the major trauma patient based upon these guidelines. Elapsed time Processes undertaken Time 0 Patient on ED trolley Within 10 minutes Reception/handover Primary survey and immediate interventions Arrive ED Establish ED monitoring Establish anaesthesia and ventilation (if required) Establish appropriate IV access, undertake venous blood gas, give analgesia +/- fluids > Section 5.e Emergency radiology Request immediate imaging: CT in stable patients, FAST and PXR in unstable patients Identify and transfer to trauma theatre if patient necessitates immediate damage control surgery Within 30 minutes Arrive ED Gain cardiovascular control Administer tranexamic acid: First bolus (if not already given) and start second infusion Any immediate radiological studies undertaken in resus complete and available for viewing Antibiotics / tetanus given Transfer to CT and start scanning Within 60 minutes Arrive ED Formal CT report available Images transferred to MTC and Network Co-ordination Service contacted Complete secondary survey and further treatments Further imaging undertaken, eg. limbs Tertiary specialist involvement, eg. ENT, maxfax > Section 10.f Disposition / transition plan made APC image transfer Within 90 minutes Transition to final destination TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05 05.d • First hour of care in the emergency department Targets for damage control resuscitation The injured patient can quickly become hypothermic, acidotic and coagulopathic in response to the injury. Damage control resuscitation aims to prevent further damage by targeting these problems. Injury Haemorrhage Coagulopathy Hypoperfusion Acidosis Hypothermia Exposure Hypothermia • limit patient exposure where possible • use a forced air warming product (eg. Bair Hugger) to maintain a normal body temperature • blood products and IV fluids should be warmed for giving Acidosis / coagulopathy Acidosis usually reflects hypoperfusion secondary to haemorrhagic shock. This hypoperfusion is also thought to be one of the initiators of the early coagulopathy seen in trauma patients that cannot be measured using the PT and APTT. 05 • control major external haemorrhage – direct pressure –tourniquets – haemostatic agent (eg. Celox™) • control internal haemorrhage – splinting fractures (femur and pelvic) • maintenance of perfusion pressure – aiming for systolic BP of 90mmHg in those without a head injury – aiming for a MAP >80mmHg in those with a head injury • early use of blood products • ensure tranexamic acid has been given (both doses) • damage control surgery, if needed TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05 • Acute care 05.e.i • Emergency radiology All imaging should be requested following discussion with the team leader and radiologist. Good communication between the trauma team and the radiology department is essential and will facilitate the service provided and enable more accurate reporting. CT The imaging modality of choice in acute severe trauma is CT. Definition of severe trauma is ISS >15. However, in the acute setting trauma CT may be deployed in patients with ISS of 8–15. A list of suggested indications for whole body trauma CT protocol is included below. In minor / moderate trauma or where one body part is injured, the CT protocol may be tailored appropriately. Caution should be applied regarding distracting injuries. Acquisition of trauma CT images should be protocol driven. This enables the imaging process to be streamlined and provide uniformity across the region. Definitive imaging should not be delayed by other less accurate investigations1. FAST imaging and plain film imaging may be indicated in certain scenarios, this is detailed in the document ‘Standards of practice and guidance for trauma radiology in severely injured patients’ published by the Royal College of Radiology1. To CT In pregnant patients modification of the pathway should be discussed between the trauma team leader and radiologist. Depending upon the mechanism and severity of injury, CT may still be the imaging modality of choice. Transfer to CT should be rapid with minimal delay. Radiology must indicate when the scanner is available and therefore when the patient can be moved. The CT trauma protocols utilised in the major trauma centre are provided for both adult (appendix 1 and 3) and paediatric polytrauma (appendix 2). Further guidance on the use of alternative protocols is available in the Royal College of Radiology document1. The general principles for polytrauma imaging include: • time is of the essence • adequate imaging coverage • avoid a ‘piecemeal’ approach and repeated visits to the CT department • optimise images obtained. For example, in pelvic fractures, arterial phase imaging is crucial for assessment of arterial versus venous bleeding • aim to keep radiation exposure as low as reasonably possible • trauma team leader to discuss CT request with radiologist. Clinical presentation should guide most appropriate imaging Suggested indications for CT imaging from vertex to symphysis in polytrauma2 are: 1.Clinical • all adequately resuscitated major trauma patients • all ventilated trauma patients • spinal injury with neurological compromise • reduced GCS (excluding isolated head injury) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05 05.e.i • Emergency radiology 2.Mechanism Mechanism may not be a reliable guide to injury. The list below should act as a guide in conjunction with clinical signs. Blunt trauma: • ejection from vehicle / thrown from motorbike • motor vehicle fatality in the same passenger compartment • motorbike / bicycle / pedestrian hit by car at ≥20mph • prolonged extrication time (>20mins) • crush injury to thorax / abdomen • fall >3m (10ft) Penetrating trauma: • blast injury (explosion / bomb) • gunshot wound Reporting: All trauma CTs should be reviewed whilst the patient is on the table, particularly for foci of active bleeding. Notify the relevant clinicians promptly. The Emergency department trauma documentation (page 9) provides a means of reliably communicating immediately life-threatening injuries to the trauma team and should be completed by the radiologist at the time of the scan. The primary CT survey / provisional report is not to be used to exclude any injuries. A formal report should be made available as soon as possible, within an hour of the end of the trauma CT. US: FAST scan should not delay definitive imaging and should only be performed by an accredited practitioner. 05 References 1 Standards of practice and guidance for trauma radiology in severely injured patients, (The Royal College of Radiologists, 2011) 2 Smith CM, WoolrichBurt L, Wellings R, Costa ML, ‘Major trauma CT scanning: the experience of a regional trauma centre in the UK’, Emerg Med J (2011); 28: 378–382 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Radiology Use hospital identification label Scans Plain films (please circle) CT scan (please circle) Time: H H : M M CXR / PXR / C-spine Time: H H : M M Head / Neck / Chest / Abdo / Pelvis / Legs / Other Transfer of images to MTC Time: H H : M M Yes / No First FAST Time: H H : M M MRI scan Time: H H : M M Initial reports To guide initial management only. Formal detailed report will follow on PACS. CT performed (please circle) Head / CSp / CAP / Vascular Airway ET placement (please circle) Satisfactory / Unsatisfactory Airway obstruction Yes / No Breathing Pneumothorax Right / Left / No Contusion/laceration Yes / No Circulation (bleeding) Thoracic Right / Left / No Pelvic Yes / No Abdominal Yes / No Soft tissue Yes / No If yes, please comment briefly: Disability Intracranial bleed Small / Moderate / Large / No Other major injuries noted (please comment): Reporting Radiologist (print name): Date: D D / M M / Y Y Signed: Time: H H : M M 9 05 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05.e.i • Emergency radiology – Appendix 1 Major Trauma Centre guidelines for CT imaging in adult blunt polytrauma Patients should attend the department on a trauma board with adequate IV access. Remove unnecessary metal objects from the imaging field. 1. Standard head CT Unenhanced axial head CT – either angled to orbitomeatal line or if suspected facial injury, spiral acquisition through brain and facial bones. Bone reconstructions on thinnest possible with edge enhancement. 2. Cervical spine CT Image from foramen magnum to T3–4. Sagittal 2mm and coronal 2mm reconstructions either on the scanner or using PACS workstation. Following head and neck imaging, if possible the patient’s arms should be placed above their head, crossed over the lower abdomen or placed on a pillow over abdomen. 3. Arterial phase – chest and abdomen Image from C6 to aortic bifurcation post IV contrast medium; trigger over ascending aorta, 100mls at 4mls/sec. Acquire thin section axial images on a soft tissue reconstruction. (If there is known or suspected pelvic injury, continue through the pelvis to below the pubic symphysis. If imaging chest to pelvis in arterial phase, consider using 150ml IV contrast medium followed by 50ml normal saline.) 4. Portal venous phase – abdomen and pelvis Image from domes of diaphragm to below symphysis pubis at 70 secs from the start of the contrast medium injection. Acquire thin section axial images on a soft tissue reconstruction algorithm. 5. Delayed phase The initial images should be reviewed whilst patient on the CT table and delayed imaging performed through all areas suspicious for active bleeding or where solid organ injury detected (particularly renal injury). Image at approximately 5 mins post IV injection, if clinically appropriate. Reformat – thoracic and lumbar spine in sagittal and coronal planes, 2mm reconstructions on CT scanner or PACS workstation. Caveats: 05 1.Known or suspected pelvic trauma: arterial phase should extend to the pubic symphysis. 2.If bladder rupture is suspected, CT cystogram should be performed if there is a catheter in situ (50mls of contrast in 450mls of normal saline – bladder filled under gravity – approximately 250–400mls). 3.Consider leg run-off in lower limb trauma with clinically suspected vascular compromise (if imaging the lower leg, may need to consider increasing IV contrast medium to 200mls and 100mls normal saline to improve bolus quality). TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05.e.i • Emergency radiology – Appendix 2 Major Trauma Centre guidelines for CT imaging in paediatric blunt polytrauma CT is the imaging modality of choice No pre-contrast imaging of the chest or abdomen Protocol: Head / C-spine – if indicated pre IV contrast medium Chest – single arterial post IV contrast medium, in inspiration if possible Abdomen/Pelvis – single portal venous phase only Consider delayed topogram / CT at 10 minutes if urinary tract injury If bladder injury or pelvic fracture, consider formal cystogram Oral contrast medium: A single dose of dilute gastrograffin 10–15 minutes before the examination can be considered if the patient is clinically able to tolerate this. If the patient is intubated, this can be given via NG tube following discussion with the anaesthetist. Scan delay times will vary according to local protocols. Intravenous contrast medium: Local protocols must be followed Within Cambridge University Hospitals Major Trauma Centre: 2mg/kg of warmed Iomeron 300 used, to a maximum of 100ml. Minimum of 10ml overall volume. If less than 10ml, a saline bolus can be given to make up to 10ml. The delay from time of injection to imaging will differ between different scanners. 05 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05.e.i • Emergency radiology – Appendix 3 Penetrating trauma CT protocol 1. Standard head CT – if involved Unenhanced axial head CT – either angled to orbitomeatal line or if suspected facial injury, spiral acquisition through brain and facial bones. Bone reconstructions on thinnest possible with edge enhancement. 2. Cervical spine CT Image from foramen magnum to T3–4. Sagittal 2mm and coronal 2mm reconstructions either on the scanner or using PACS workstation. Following head and neck imaging, if possible the patient’s arms should be placed above their head, crossed over the lower abdomen or placed on a pillow over the abdomen. 3. Arterial phase – chest and abdomen Image from C6 to aortic bifurcation post IV contrast medium; trigger over ascending aorta, 100mls @ 4mls/sec. Acquire thin section axial images on a soft tissue reconstruction. Consider also imaging the neck in the arterial phase, following IV contrast medium, to assess vascular injury secondary to penetrating injury. 4. Portal venous phase – abdomen and pelvis Image from domes of diaphragm to below symphysis pubis at 70 secs from the start of the contrast medium injection. Acquire thin section axial images on a soft tissue reconstruction algorithm. 5. Delayed phase The initial images should be reviewed whilst patient is on the CT table and delayed imaging performed through all areas suspicious for active bleeding or where solid organ injury is detected or suspected (particularly renal injury). Image at approximately 5 mins post iv injection, if clinically appropriate. Oral / rectal contrast medium: In suspected penetrating trauma to the abdominal or pelvic cavity, rectal and oral contrast medium can be helpful in the detection of bowel injury. Oral contrast medium – dilute oral contrast medium can be administered orally or via NG tube. Rectal contrast medium – give 1000ml of diluted iodinated contrast medium delivered via a drip system with a ballooned Foley catheter inserted within the rectum. 05 If bladder injury is suspected, CT cystogram or formal cystogram can be undertaken. If there is a bladder catheter in situ – fill bladder under gravity with 50mls of contrast medium in 450mls of normal saline. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05 • Acute care 05.e.iv • Interventional radiology (IR) The role of IR in major trauma is to stop haemorrhage as quickly as possible with minimal interference as part of damage control resuscitation. Information supplied by the head to pelvis CT scan is key to informing the decision-making process. •Trauma team leaders should be aware of possible indications for IR in trauma as detailed in the table below. •Decisions on the use of IR should be made in conjunction with a senior clinician from the appropriate specialty. •Once requested and the patient is on site, IR should be available within 30 minutes of referral. Site Non-operative management Interventional radiology Damage control surgery Thoracic aorta No role except in small partial thickness tears Stent graft for suitable lesions Ascending aortic injury or arch injury involving great vessels Abdominal aorta No role Occlusion balloon, stent graft for suitable lesions Injury requiring visceral revascularisation or untreatable by EVAR Peripheral / branch artery No role Occlusion balloon, stent graft for suitable lesions Any lesion which cannot rapidly be controlled or which will require other revascularisation Kidney Subcapsular or retroperitoneal haematoma without active arterial bleeding Active arterial bleeding, embolisation or stent graft Renal injury in association with multiple other bleeding sites or other injuries requiring urgent surgery Spleen Lacerations, haematoma without active bleeding or evidence of false aneurysm Active arterial bleeding or false aneurysm Packing or splenectomy for active bleeding in association with multiple other bleeding sites Subcapsular or intraperitoneal haematoma or lacerations without active arterial bleeding Active arterial bleeding Pelvis Minor injury with no active bleeding Focal embolisation for arterial injury (bleeding, false aneurysm or cut-off) External compression and subsequent fixation if bleeding from veins or bones Intestine Focal contusion with no evidence of ischaemia, perforation or haemorrhage Focal bleeding with no evidence of ischaemia or perforation. Or, to stabilise patient, allow interval laparotomy pending treatment of other injuries Ischaemia or perforation requiring laparotomy +/bowel resection Liver Focal embolisation for focal lesion Proximal embolisation for diffuse injury Focal embolisation if possible Non-selective embolisation if multiple bleeding sites as long as portal vein is patent IR facilities are available at the MTC 24/7, with availability also in some TUs. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Packing if emergency laparotomy needed with subsequent repeat CT and embolisation if required 05 05.g • Trauma team debrief It is important to take a few minutes to debrief after each trauma call. This tool is a suggested format for these debriefs and follows the after action review (AAR) method. Trauma call: Date D D / M M / Y Y Y Y Time H H : M M Debrief: Date D D / M M / Y Y Y Y Time H H : M M Debrief lead: Trauma team leader? Yes / No Attending What was expected to happen? What actually happened? Why was there a difference? What can we learn for the future? Any other comments/issues Please share these with your Trauma Committee. Please consider sharing with the Trauma Network if you feel it would be helpful. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 05 06 Emergency treatment guidelines 06 06 • Emergency treatment guidelines Catastrophic haemorrhage 06.b.i • Use of Celox™ / haemostatic This is ideally a two-person technique Operator 1 Operator 2 Apply pressure into wound through normal dressing Open a fresh dressing. Open haemostatic (hold away from face and carefully tear across the top) Now work closely together Remove dressing 1 2 Immediately apply pressure through a fresh dressing for 3 minutes Unravel and insert Celox™ gauze packing tightly 3 May be used internally by trained surgeons as haemostatic measure 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 • Emergency treatment guidelines Catastrophic haemorrhage 06.b.ii • Use of tourniquets Used for the control of massive bleeding from a limb wound. The CAT is the commonest tourniquet in use. To apply a CAT tourniquet • apply as close to the wound as possible but not on wound edges • ensure the strap is fed through both loops of the buckle and pull tight • turn the windlass until bleeding stops • secure the windlass in the windlass holder •if bleeding is not controlled apply a second tourniquet proximally on the single boned portion of the limb • record time on tourniquet and in notes • dress wound appropriately and elevate limb if practical •if a trial release is attempted, this should be performed by one turn of the windlass at a time with short intervals to assess for bleeding 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network ✓ ✓ 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 • Emergency treatment guidelines Catastrophic haemorrhage 06.b.iii • Use of tranexamic acid in trauma patients Tranexamic acid is an antifibrinolytic agent and inhibits the activation of plasminogen to plasmin. Trial data (CRASH-2)1 showed that the administration of tranexamic acid to adult trauma patients with, or at risk of, significant haemorrhage, within 8 hours of injury significantly reduces all-cause mortality with no apparent increase in vascular occlusive events. •Early use of tranexamic acid should be considered for all patients with trauma and significant haemorrhage. •Patients with isolated head injury should not routinely receive tranexamic acid as risk of thrombosis exists. • Use within 3 hours of injury is recommended. •Initial use of tranexamic acid should be avoided when time from injury is known or suspected to be greater than 3 hours. •Tranexamic acid is given as 1 gram loading dose in 100ml 0.9% normal saline over 10 min in a separate line from blood or blood products. •Infuse a second 1 gram dose of tranexamic acid in 0.9% normal saline over 8 hours. •There is no evidence from randomised trials to support additional administration of tranexamic acid in trauma patients after the initial two doses. Further use should be discussed with an on-call haematology consultant. > Section 11.a Tranexamic acid The East of England Ambulance NHS Trust has developed a PGD in conjunction with the Trauma Network for paramedic administration of tranexamic acid in the first 3 hours after injury. References 1 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network E ffects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial, The Lancet, Vol 376, issue 9734, 23-32; 3 July 2010 06 06.b.iv • Massive blood loss protocol East of England Regional Transfusion Committee Massive blood loss in adults ≥ 40% loss of total blood volume 4 litres in 24 hours 2 litres in 3 hours > 150ml/min Get help Contact Transfusion Laboratory Contact senior member of clinical team. Contact senior ward nurses Contact portering services Contact Transfusion Ask Transfusion to ‘initiate massive blood loss protocol’ Assess ABC IV access Check patient identification 2 large cannula Send blood samples, cross-match, FBC, coagulation, biochemistry Consider arterial blood gas measurement Send FBC and coagulation samples after every 5 units of blood given Resuscitate IV warm fluids – crystalloid or colloid Give oxygen Give blood Before transfusion • Check patient ID • Use wristbands Blood loss >40% blood volume is immediately life-threatening Give 4 units via fluid warmer. Aim for Hb>8g/dl Give Group O Rh D negative if immediate need and/or blood group unknown Blood transfusion lab will provide group specific / cross-matched red cells as required Blood loss >40% blood volume • 1500–2000mls loss • Pulse > 120, RR > 30 • Hypotensive • Urine < 20mls/h Prevent coagulopathy Primary MBL pack • Blood 5 units • FFP 4 units Reassess and document Anticipate need for platelets and FFP after 4 units blood replacement and continuing bleeding Give Primary Massive Blood Loss (MBL) Pack Order Secondary Massive Blood Loss (MBL) Pack Correct hypothermia Correct hypocalcaemia (keep ionised Ca > 1.13mmol/L) Contact Haematologist Get help to stop bleeding MS120303.V2.0212 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Secondary MBL pack • Blood 5 units • FFP 4 units • Platelets • Cryoprecipitate Contact surgeons, gastroenterologists, obstetricians as appropriate 06 • Emergency treatment guidelines Catastrophic haemorrhage 06.b.v • Use of recombinant FVIIa (rFVIIa) rFVIIa is not recommended as a first line treatment for bleeding associated with trauma. It will be effective only when sources of major bleeding have been controlled. A recent multi centre randomised placebo controlled study demonstrated safety of rFVIIa in trauma patients with active bleeding1. It should be noted that recombinant factor VIIa is not licensed for the treatment of massive blood loss and its use is associated with a theoretical increased risk of thromboembolic complications. The decision to administer rFVIIa should be made by the duty consultant haematologist. Indications for use of rFVIIa • Patients with haemorrhage secondary to trauma who continue to bleed despite conventional management strategies and treatment with tranexamic acid and adequate blood product replacement according to the massive haemorrhage protocol should be considered for treatment with rFVIIa. • Ideally platelets should be > 50,000 x109/l and fibrinogen >1.5g/l prior to use. • The decision to use rFVIIa should be made by two consultants (a consultant haematologist and the trauma consultant treating the patient). • Treatment dose is 90µg/kg as a slow IV bolus over 2–5 minutes. • A second dose of 90µg/kg may be given after 2 hours if required. • Caution required if patient has a history of thromboembolic disease. • For this off-license use, consent should be obtained from the patient if possible prior to use. 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 • Emergency treatment guidelines Airway compromise 06.c.i • Surgical airway Indications Can’t intubate, can’t ventilate, Patients >12 yrs old Equipment scalpel Consider as primary airway in massive maxfax trauma tracheal dilators Cricothyroid membrane 10ml syringe / tube tie Technique 15ch bougie •Identify the cricothyroid membrane (fig 1). Clean the area. • Use a scalpel to make a deep horizontal incision through skin and cricothyroid membrane (fig 2). 6.0 tracheostory tube Fig 1. Cricothyroid membrane • Remove scalpel and insert dilators, spreading to hold open the hole (fig 3). • Insert size 6.0 tracheostomy tube and inflate cuff, bougie may be helpful. • Attach capnograph and confirm EtCO2 detection, auscultate. • After oxygenating, pass suction catheter for blood / secretions. Fig 2. Incision • Secure tube with tracheostomy tie. Fig 3. Inserting dilators 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 • Emergency treatment guidelines Circulation problems 06.f.ii • Neurogenic shock Introduction Neurogenic shock is due to disruption of the sympathetic outflow as a result of an injury to the spinal cord. The main clinical signs of a patient in neurogenic shock are: Hypotension – Due to passive dilatation of the vascular system. This can lead to decreased cardiac output as well as over-infusion of fluid replacement if not recognised. Bradycardia – Due to unopposed vagal stimulation. Cardiac syncope can occur with trachea-oesophageal stimulation. Poikilothermia – Due to dilatation of the vascular network. Patient becomes susceptible to their surroundings leading to hypo or hyperthermia if not insulated. The higher the spinal lesion, the more pronounced the signs. A blood pressure of 60/40mmHg would not be unusual in a cervical spinal cord injury. It is important that fluid replacement is carefully monitored to ensure patients in neurogenic shock are not over-infused leading to pulmonary oedema and respiratory distress. A clinical suspicion of neurogenic shock can be made from the key signs such as hypotension, bradycardia, neurological deficit and warm, dry skin. Immediate management The initial evaluation and care of the patient with potential neurogenic shock is the same as for all trauma patients, that is, rapid identification and stabilisation of life-threatening injuries. • Monitor BP, pulse, CVP, mean arterial pressure and urinary output. • Measure the above every 15 minutes and watch for any trends. •Massive fluid replacement should be avoided. In the case of polytrauma, fluid replacement should be given carefully whilst monitoring the patient carefully. •If significant hypotension persists with no evidence of blood loss, consider the use of vasopresser drugs to replace the lost neurogenic vasoconstriction. •TED stockings should be applied to reduce the risk of DVT but also to help replace some of the lost muscle resistance. •Avoid rolling the patient on to the left side for a prolonged time as this can cause increase vagal stimulation leading to cardiac syncope. 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 • Emergency treatment guidelines Circulation problems 06.f.iv • Massive facial trauma Indications Massive maxillofacial haemorhage Intubation must be performed first Equipment 2 nasal epistats 2 dental bridges cervical collar 50ml syringe saline Technique • Insert nasal epistats into each nostril – DO NOT INFLATE YET. •Insert dental bridges either side of the ET tube, between upper and lower molars and with point of wedge towards the back of mouth. • Apply well fitting cervical collar (to stabilise mandible). • Inflate posterior balloon (WHITE VALVE) with 10mls saline. • Inflate middle balloon (GREEN VALVE) with 20–30mls saline. • Repeat in opposite nostril. 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 • Emergency treatment guidelines Disability 06.g.i • Head injury Early accurate identification of any brain injury and the prevention of further brain injury from the time of any trauma is a major focus of care. Relatively simple measures which can be instigated early may reduce secondary brain injury. Avoidance of hypoxia and hypotension is fundamental. This TEMPO guidance does not replace the NICE head injury guidance (56) but should be used in the context of the multiply injured or moderate to severe head injured patient. Primary brain injury Reduced by prevention programmes that modify the environment, behaviour and any injury force delivered to the brain in a particular incident Secondary brain injury In the context of severe trauma, secondary brain injury may be reduced by optimisation of basic physiological parameters: A Airway obstruction • aggressive basic airway management as GCS allows •early intubation, particularly for the agitated high GCS head injury or GCS <8 B Oxygenation • maintaining SpO2 >95%, PaO2 >13kPa (check arterial blood gas) • aiming Hb >12g/dl Carbon dioxide •in the intubated patient, maintaining a normal end-tidal CO2 and PaCO2 4–5kPa • titrate end-tidal CO2 to the arterial values C Blood pressure • in confirmed isolated traumatic brain injury, maintain MAP >90 •in multiply injured patient (traumatic brain injury plus non-compressible bleeding), maintain MAP >70. Stop the bleeding D Normoglycaemia Impaired venous outflow • loose cervical collar appropriately fitted • tube ties not overtight •in confirmed isolated traumatic brain injury, the whole patient tilted head-up 30o •in multiply injured patient (traumatic brain injury plus non-compressible bleeding), patient flat Seizure activity • aggressive management but no place for prophylactic anticonvulsants All patients with moderate to severe traumatic brain injury should be managed as if they have a spinal injury until this is excluded radiologically. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 06.g.i • Head injury Open head injuries The wound should be covered with saline soaked gauze and pneumococcal vaccine (Pneumovax) given. IV antibiotics are not necessary in the early stages. Raised intracranial pressure (ICP) Signs of a raised ICP include • asymmetric pupils •bradycardia •hypertension (NB. in these circumstances hypertension is a symptom of raised intracranial pressure and should be managed by reducing ICP) • fixed dilated pupils Adult patients with a head injury and signs of a raised ICP should be given either • mannitol 1g/kg over 10mins • hypertonic saline 5%, 100ml bolus > Section 11.d Transfer infusions In patients who have been intubated, attention must also be paid to adequate sedation and analgesia, both of which have significant impact on intracranial pressure. Standard infusions of 2% propofol and neat fentanyl (as per transfer guidelines) should be started. Neurotrauma referral All patients with brain injuries must be discussed with the Trauma Network Co-ordination Service prior to any transfer. Trauma units do not need to contact neurosurgery to discuss these patients. 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 • Emergency treatment guidelines Disability 06.g.ii • Spinal cord injury (SCI) referrals • If the patient is from Bedfordshire, Hertfordshire, Essex or Cambridge, and within 4 hours of diagnosis of SCI to MTC (or TU), contact the NCS on 0300 330 3999 and request contact be made with Stoke Mandeville Hospital (or Stanmore) via the single point of contact referral number 0844 892 1915. Referral data must then be completed online via nww.spinalreferrals.nhs.uk • If the patient is from Norfolk, Suffolk or northern Cambridgeshire, and within 4 hours of admission to MTC (or TU), contact the NCS on 0300 330 3999 and request contact be made with diagnosis of SCI to Sheffield SCIC by calling 0114 243 4343 and asking to speak to the duty spinal cord injury consultant Written referral must then be faxed to 0114 271 5649. • Involve physiotherapists immediately – particularly for chest management. • Undertake accurate pre (and post) surgery ASIA scoring. 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 • Emergency treatment guidelines Environmental injury 06.h.iv • Ballistic injuries Approach to ballistic injuries – for use in the pre-hospital phase Interventions <C>ABCDE appoach Penetrating head injury Limbs Haemorrhage control If appropriate to re-examine wounds proir to surgery, redress with iodine-soaked gauze and secure with crepe bandage. Splint long bone injuries Analgesia Low GCS = airway at risk: lateralising signs = need surgical assessment Airway injury • above cricothyroid membrane: think cricothyroidotomy • below cricothyroid membrane: think tracheostomy Chest Pneumonothorax? Haemothorax? Critical decisions Identify time critical injuries (non-compressible haemorrhage) requiring urgent surgery Caveats • check front and back of casualty • bullets and fragments cross cavities Abdomen Internal bleeding? Emergency theatre Consider need for NG tube Fluid resuscitation 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06.h.iv • Ballistic injuries Management of ballistic injuries – for use in ED Interventions <C>ABCDE appoach Penetrating head injury Critical decisions Consider absolute requirement for surgery Decision must be tempered by patient’s condition and anticipation of further inbound patients Limbs Follow guidance for pre-hospital phase Antibiotics: Co-amoxiclav 1.2g 1V If penicillin allergic: Vancomycin 15mg/kg 1V + Ciprofloxacin 200mg 1V + Metronidazole 500mg 1V Investigations • FBC • cross match blood • blood gases for critical patients • urea and electrolytes where indicated • plain radiology/USS/ CT where indicated Follow guidelines for pre-hospital phase plus consider RSI obtain CT antibiotics Airway injury • above cricothyroid membrane: think cricothyroidotomy • below cricothyroid membrane: think tracheostomy; move to emergency surgery Chest Follow guidelines for pre-hospital phase plus antibiotics Abdomen Fluid resuscitation Internal bleeding? Confirm with FAST USS or DPL. Antibiotics Tetanus prophylaxis for the non-immune Urinary catheter with hourly measurement for critical patients 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 • Emergency treatment guidelines Environmental injury 06.h.v • Blast injuries ICRC (International Committee of the Red Cross) describe three injury patterns for an antipersonnel mine. Management <C>ABCDE appoach BMJ 1991;303:1509–12 Perforating ear drum Blast lung • uncommon in survivors who reach hospital • may develop over 24–48 hours Consider rFV11a • perforated TMs are NOT a reliable indicator that blast lung will develop • hearing loss and/or balance disorder requires urgent ENT assessment Pattern 3 From handling mines: deminers removing mines or children playing with them. Severe head, face, eye injuries Management <C>ABCDE appoach Have a high index of suspicion for bowel injury – clinical diagnosis, ultrasound and CT can be inconclusive: diagnostic peritoneal lavage may reveal vegetable matter and raised amylase/ white count • Associated ballistic injury? • Associated blunt injury? • Associated burn? Pattern 1 Usually from standing on buried mine • usually sustain traumatic amputation of foot or leg • other leg often affected • one or both legs may need amputation • injuries to genitalia are common Pattern 2 Multiple fragments from mine triggered near casualty Injuries to face, head, chest, abdomen and limbs 06 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 • Emergency treatment guidelines 06.j • End of life care and organ donation pathway Clinical context There are over 8,000 people waiting for an organ transplant in the UK. The identification of potential donors in emergency departments (ED) will increase rates of donation and will ensure patients’ previously held wishes are fulfilled. Eastern Region Organ Donation Service Team It has been suggested that the overall incidence of brain stem death in the UK may be falling because patients with catastrophic brain injury are not admitted to critical care and have treatment withdrawn in the ED, meaning formal brain stem death testing is not carried out. Pager: 07659 117499 The potential for donation within the ED mainly comes from severely brain injured patients; either from trauma or acute medical catastrophe, eg. sub-arachnoid haemorrhage, or in patients who are post cardiac arrest with return of spontaneous circulation (ROSC). Best practice This pathway has been written to advise and guide senior members of ED staff in decision-making around organ donation. Where a ventilated patient has suffered a catastrophic traumatic or medical event, and the decision has been made that further treatment is futile, a specialist nurse for organ donation (SNOD) should be contacted as the next step. When the decision has been made that further treatment is futile, it is essential to continue to care for patients in a critical care environment while donation is being considered / explored. It is important to consider if the patient is likely to progress to brain stem death. Donation via brain stem death results in a greater number of donated organs. The Academy of Medical Colleges and the Intensive Care Society state that best practice is to undergo formal brain stem death testing where brain stem death is likely but irrespective of organ donation. Please seek the advice of your consultant intensivist. Unless raised by the family, the issue of donation should not be discussed until the decision to withdraw life-sustaining treatment has been understood by the family. It is best practice to ‘decouple’ conversations regarding patient prognosis, treatment futility and death with conversations exploring organ donation, ensuring these two distinct clinical conversations are had at separate times. When a decision has been made to approach families about organ donation best evidence suggests that a collaborative approach with a senior clinician and a SNOD should be undertaken. Facilitating donation takes many hours and agreed local policies should guide where the most appropriate environment is to care for these patients (ICU, ED or other capable areas such as theatres / recovery). An agreed local policy should suggest potential alternative areas and staffing. Patients who die in the ED Patients in whom further treatment is futile, and who are dying, should routinely be started on the Liverpool Care Pathway. Patients who die in the ED from any cause may be suitable eye and tissue donors. The next of kin should be offered this routinely and, if they consent, tissue services should be contacted on 0800 432 0559. They can offer advice and will contact the family to answer questions and go through the formal consenting process. Eyes and tissues for donation can be retrieved up to 24 hours after death. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 06 06.j • End of life care and organ donation pathway Intubated trauma or medical patient in ED Decision further treatment is futile / prognosis is death Maintain current treatment Contact specialist nurse for organ donation on 07659 117499 for advice regarding medical suitability for donation Medically suitable for donation Medically unsuitable for donation Next of kin informed further treatment is futile Withdrawal of treatment, start on Liverpool Care Pathway and discussion about tissue donation after death Consideration of appropriate time / location to approach family. Is patient likely to progress to brain death (all potential brain dead donors should be maintained for formal brain stem death testing) Collaborative approach for donation by clinician and specialist nurse for organ donation (in ED or after transfer to ITU) Verbal consent from next of kin for donation 06 Seek to facilitate donation from most appropriate setting (ITU/ED) Refusal of consent for donation Withdrawal of treatment. Discussion about tissue donation TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 07 Paediatrics 07 08 Rehabilitation 08 08 • Rehabilitation Purpose of guidance By the very nature of rehabilitation, incorporating guidelines into a manual of operations and procedures is challenging. It is therefore not the intention of this rehabilitation section to provide comprehensive guidance on all aspects of the myriad of rehabilitation interventions that major trauma patients may need. Rather, it is intended to provide an overview of the key rehabilitation processes that will be required and the key rehabilitation themes that will need to be considered during the in-patient phase of the major trauma pathway. This will guide the reader to consider the broader aspects of the rehabilitation of the trauma patient and to seek help and guidance through the Network Co-ordination Service (NCS) where necessary. A toolbox of assessment tools and outcome measures has also been provided (see separate manual) to aid patient management and to help to demonstrate improved outcomes for this patient population following the advent of the Trauma Network. Dr Clive Bezzina Specialist Trainee in Rehabilitation Medicine Dr Kate McGlashan Clinical Lead for Trauma Rehabilitation Helen Young Trauma Rehabilitation Co-ordinator TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 08 • Rehabilitation International Classification of Functioning, Disability and Health Framework (ICF) 08 The original classification of impairment, disability and handicap by the World Health Organisation (1980) informs the basis for an understanding of rehabilitation. This was updated in 1997, with the aim of making the tool more capable for use in different countries and cultures, and more acceptable to different sociological and health-care disciplines. The ICF is based on the classification of health and healthrelated domains, and helps describe changes in body structure and function. It describes what a person with a health condition can do in a standard environment (capacity), and what they actually do in their usual environment (performance). In also taking into consideration contextual factors (both environmental and personal), the description of an individual’s functioning is more complete. ICIDH – (1980) ICF (1997) Impairment stayed Impairment Disability became Activity Handicap became Participation Impairment •loss or abnormality of a body structure or of a physiological or psychological function Activity •‘nature and extent of functioning at the level of the person. Activities may be limited in nature, duration and quality’ • concentrates on doing Participation •‘is the nature and extent of a person’s involvement in life situations in relation to impairments, activities, health conditions and contextual factors’ • concentrates on being • shifts from emphasising people’s disabilities to their level of health •acknowledges that every human being can experience a decrement in health and therefore experience some disability • thereby ‘mainstreams’ experience of disability as a universal human experience International Classification of Diseases (ICD-10) and ICF • ICD-10 & ICF are complementary • ICD-10 is mainly used to classify causes of death • ICF classifies health References Halbertsma J, Heerkens YF, Hirs WM, ‘Towards a new ICIDH: International Classification of Impairments, Disabilities and Handicaps’, Disability and Rehabilitation (2000); 22:144–56 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation 08.a • Goal setting 08 Patient-centred goal-planning is at the centre of rehabilitation. Goal-planning is a recognised and effective way to plan, direct and measure the success of a rehabilitation programme. Goals should be SMART Sspecific Mmeasurable Aachievable Rrelevant Ttime-limited Goals can be both short and long term and should be set at the level of whole team intervention as well as for the individual clinician. Failure to achieve a goal should be categorised under one of the following variance headings: 1.patient factors (eg. patient unwell) 2.staff factors (eg. staff sickness) 3.reasons due to intrinsic system factors (eg. equipment failure) 4.reasons due to extrinsic factors (eg. funding) Examples of goals setting for a patient with a brain injury Date SMART goal Target date Outcome Variance 03/03/2012 For John to walk 10m with assistance 1 of plus handling belt in <25 seconds 10/03/2012 Achieved 03/03/2012 For John to initiate using call bell to ask 17/03/2012 for help with toileting and remain continent during day on 7/14 days Patient factors Not – intercurrent achieved UTI Outcome measures/ assessment tools • Goal Attainment Scaling References Royal College of Physicians and British Society of Rehabilitation Medicine, Rehabilitation following acquired brain injury: national clinical guidelines, (Turner-Stokes L, ed) London: RCP, BSRM (2003) ‘Writing SMART rehabilitation goals and achieving goal attainment scaling: a practical guide’, Bovend’Eerdt TJ, Botell RE, Wade DT, Clinical Rehabilitation (2009) Apr; 23 (4): 352–61 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation 08.b • Mental Capacity Act 2005 Assessment of mental capacity The underlying philosophy of the Mental Capacity Act (MCA) is to ensure that those who lack capacity are empowered to make as many decisions for themselves as possible and that any decision made, or action taken, on their behalf is made in their best interests. The five key principles of the Act are: 1.Every adult has the right to make his or her own decisions and must be assumed to have capacity to make them unless it is proved otherwise. 2.A person must be given all practicable help before anyone treats them as not being able to make their own decisions. 3.Just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision. 4.Anything done or any decision made on behalf of a person who lacks capacity must be done in their best interests. 5.Anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms. Assessing mental capacity Four point test of capacity – the person must be able to: 1.understand the information given to them 2.retain the information long enough to be able to make a decision 3.weigh up the information available to make a decision 4.communicate their decision Best interests If a person is deemed to not have capacity to make a decision regarding their health and welfare, a decision can be made on their behalf in their ‘best interests’ except regarding the following circumstances: • marriage or civil partnership •divorce • sexual relationships •adoption •voting The statutory checklist must be consulted. Decisions can be made on the basis of weighing up the advantages and disadvantages of the issue in question, eg. transfer to a specialised rehabilitation facility under the headings of medical, emotional and welfare pros and cons. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 08.b • Mental Capacity Act 2005 Independent Mental Capacity Advocate (IMCA) 08 In cases where a patient has no one to support them with major decisions an IMCA can be appointed. An IMCA will only be involved in specific circumstances: 1.Where the decision is about serious medical treatment provided by the NHS. 2.Where it is proposed that the person is moved into long-term care involving more than 28 days in hospital (eg. transfer to a spinal injuries unit) or eight weeks in a care home. 3.Where a long term move (more than eight weeks) to different accommodation is proposed, such as care home or nursing home. Court of Protection It is essential to check if a patient has a pre-arranged Lasting Power of Attorney under the Court of Protection. These can be for property and affairs and for personal welfare. A Deputy can be appointed to an individual after capacity has been lost through application to the Court of Protection. Deprivation of Liberty Safeguards (DOLS) These provide a legal framework to prevent unlawful deprivation of liberty occurring. The Mental Capacity Act (MCA) DOLs apply to anyone: • aged 18 and over •who suffers from a mental disorder or disability of the mind such as dementia, a profound learning disability or brain injury •who lacks the capacity to give informed consent to the arrangements made for their care and/or treatment •for whom deprivation of liberty (within the meaning of Article 5 of the European Convention on Human Rights) is considered after an independent assessment to be necessary in their best interests to protect them from harm The safeguards cover patients in hospitals, and people in care homes registered under the Care Standards Act 2000, whether placed under public or private arrangements. The aim is to ensure people can be given the care they need in the least restrictive regimes whilst safeguarding their rights. One likely scenario when Deprivation of Liberty Safeguards may need to be considered would be in the case of a wandering patient in post traumatic amnesia requiring environmental restraint to prevent harm. Advance decisions to refuse treatment An advance decision allows an individual to set out particular types of treatment they do not want should they lack the capacity to decide this for themselves in the future. Advance decisions are legally binding and must be followed by doctors and other health professionals, as long as they meet certain conditions. At the time that the decision is made the person must be over 18 and have the mental capacity to make such a decision. The documents should make clear which treatments are being refused and the document should explain which circumstances the refusal refers to. The doctor needs this information to decide whether an advance decision is valid and applicable to a particular treatment. References Mental Capacity Act 2005 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation 08.c • Traumatic brain injury (TBI) 08 In civilian life, the vast majority of head injuries are due to acceleration / deceleration forces resulting in closed head injuries. Risk factors for sustaining a head injury include male sex, younger age (peak 15–24 years with a secondary peak in the elderly) alcohol, lower socioeconomic status and a history of psychiatric disorder. The sequelae of head injury are often long-term and can be profound, with significant psycho-social and socio-economic consequences. Early, appropriate rehabilitation provides the opportunity to actively manage the consequences of the primary brain injury and reduce secondary complications thereby improving outcome. MDT: Inpatient clinical management considerations (acute phase) • optimisation of respiratory function • nutrition, hydration and swallowing •24 hour postural management (incorporating pressure care and spasticity management) • heterotopic ossification • pain management • bladder and bowel management •communication •the potential for autonomic storming (also known as paroxysmal autonomic instability with dystonia (PAID)) • management of prolonged disorders of consciousness • management of cognitive and neuro-psychiatric issues including – post traumatic amnesia (inability to lay down new memories) – executive dysfunction – agitation and aggression Outcome measures/ assessment tools • Rancho Los Amigos levels of cognitive functioning • Rehabilitation Complexity Score Extended • Glasgow Coma Score • Glasgow Outcome Scale Extended • Barthel ADL Index • Northwick Park Dependency Score • FIM/FAM – disorientation and wandering – disinhibition • assessment under the Mental Capacity Act / Deprivation of Liberty safeguards • family and carer support Other actions: •Communication can be made with the trauma rehabilitation co-ordinator for advice and information. •Refer to the Directory of Services to provide guidance on potential transfer of care options. Patients with severe injuries are likely to require Level 1 specialised rehabilitation services. References Head injury triage, assessment, investigation and early management of head injury in infants, children and adults (NICE, 2007) Royal College of Physicians and British Society of Rehabilitation Medicine, Rehabilitation following acquired brain injury: national clinical guidelines, (Turner-Stokes L, ed) London: RCP, BSRM (2003) Early management of patients with a head injury: a national clinical guideline (SIGN, 2009) Guidelines for the Management of Severe Traumatic Brain Injury, 3rd edn (Brain Trauma Foundation et al, 2007) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08.c.i • Traumatic brain injury (TBI) Pathway 08 HOSPITAL & INPATIENT SERVICES Advice, information and advocacy Code 110 Traumatic brain injury (TBI) Case management Code 140 Equipment/ assistive technology Code 135 Mobility/ transport Code 130 Voluntary activity Code 125 Community activity Code 120 Trauma Unit Emergency Department COMMUNITY & OUTPATIENT SERVICES Major Trauma Centre Emergency Dept Minor head injury inpatient management Code 05 Traumatic head injury outpatient clinic Code 85 Home Community rehab Code 70 Observation ward Code 05 Trauma Unit acute supportive rehab (ASR2) Code 20 Non-major trauma centre acute supportive rehab (ASR1) Code 10 Major Trauma Centre acute supportive rehab (ASR) Code 10 Active participation rehab Code 40 (Level 2) Active participation rehab Code 40 (Level 1) Slow stream rehab Code 60 Behavioural rehab Code 50 Rapid access acute rehab (RAAR) Code 30 Support at home/in the community Code 115 Transitional rehabilitative accommodation Code 75 Specialist TBI nursing homes Code 105 Intensive psychological rehab Code 80 Vocational rehab Code 90 Lifelong maintenance rehab Code 70 Please refer to the East of England Trauma Network Directory of Services (DOS) for full code descriptions Based on the model developed by the Eastern Head Injury Group; Pickard, Seeley, Kirker et al, Journal of the Royal Society of Medicine (August 2004) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Traumatic brain injury 08.c.ii • Post traumatic seizures 08 A post traumatic seizure (PTS) refers to an initial or recurrent seizure episode, not attributable to another obvious cause, after penetrating or non-penetrating traumatic brain injury (TBI). Post traumatic epilepsy refers to recurrent late seizure episodes, not attributable to another cause. Immediate: within 24 hours Early: within seven days Late: after seven days Risk factors • Glasgow Coma Scale score of < 10 • cortical contusion • depressed skull fracture • epidural haematoma • intracerebral haematoma • wounds with dural penetration • seizure within the first week of injury • prolonged length of coma • prolonged length of post traumatic amnesia Risk of seizures is greatest in the first two years following TBI, with 80% occurring within this timeframe. The risk of PTS decreases with time and reaches the normal value for the population at around five years post injury. Incidence • 5% to 7% of all hospitalized patients with TBI • 11% of patients with severe non-penetrating TBI • up to 35% to 50% of patients with penetrating TBI Suggested, evidence-based approach •Anti epileptic drugs (AED) to be prescribed during first seven days following TBI for the prevention of early seizure (eg. phenytoin, carbamazepine). •In patients with no seizures or seizures in the first 48 hours only, withdraw AED after seven days. •Always anticipate the development of seizures by having appropriate emergency treatment written up on drug chart (eg. buccal midazolam). • If late seizures develop, treat with appropriate AED. Rehabilitation considerations •commonly used AEDs (phenytoin, carbamazepine, valproate) may all impair cognitive function especially memory • side-effect profiles differ between different drugs • check AEDs stopped after seven days when appropriate • seizure management education for patient, family and carers • DVLA advice TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network References Royal College of Physicians and British Society of Rehabilitation Medicine, Rehabilitation following acquired brain injury: national clinical guidelines, (Turner-Stokes L, ed) London: RCP, BSRM (2003) Brain Injury Special Interest Group of the American Academy of Physical Medicine and Rehabilitation, ‘Practice parameter: antiepileptic drug treatment of posttraumatic seizures’, Arch Phys Med Rehabil (1998); 79: 594–597 08 • Rehabilitation Traumatic brain injury 08.c.iii • Autonomic storming (paroxysmal autonomic instability with dystonia (PAID)) 08 15–33% of patients following severe traumatic brain injury (GCS 8 or less) can develop an exaggerated stress response which goes by many names in the literature such as dysautonomia, paroxysmal autonomic instability with dystonia, autonomic dysfunction syndrome and diencephalic seizures. All refer to the sequelae of an overactive, under-inhibited sympathetic nervous system. The exact pathophysiology is unknown, but there is an imbalance or disassociation between the sympathetic and parasympathetic nervous systems. The incidence of sympathetic storming appears to be greater in patients with diffuse axonal injury and brain stem injury. Clinical diagnosis Various diagnostic criteria exist but Blackman et al (2005) include: • temperature of 38.5˚c or greater •hypertension • tachycardia > 130bpm • respiratory rate > 40 breaths per minute • intermittent agitation •diaphoresis •dystonia These features need to occur for at least three days with at least one cycle per day for a diagnosis to be made and not all of these symptoms may occur. Episodes are often unprovoked, but can be precipitated by routine care tasks, eg. turning and suctioning. Early episodes may be masked by sedation or the use of paralysing drugs. Autonomic storming occurs with a mean duration of 74 days post injury, hence it may happen after transfer outside of critical care and in a rehabilitation setting. References Kishner S (undated), Post Head Injury Autonomic Complications, [on-line] http://emedicine.medscape. com/article/325994overview Lemke DM, ‘Sympathetic storming after severe traumatic brain injury’, Crit Care Nurse (2007); 27: 30–37 Baguley IJ, Cameron ID, Green AM, Slew-Youman S, Marosszeky JE, Gurka JA, ‘Pharmacological management of dysautonomia following traumatic brain injury’, Brain Injury (2004); 18: 409–417 Adverse effects There is a risk of secondary brain insult from the widespread effects of untreated sympathetic storming, including hypertension, cerebral hypoxia, hyperglycaemia, hyperthermia, arrhythmias, hypernatraemia and rhabdomyolysis. Clinical management Treatment is symptomatic. As with many other brain injury related conditions, the symptoms are treated independently, and there is no specific treatment of the underlying cause (neural damage). Due to the wide array of neurotransmitters that are involved in the management of the sympatmetic nervous system, a wide array of medications that impact upon those neurotransmitters may be useful. Opiate receptor agonists, dopamine agonists, beta-blockers, alpha blockers, GABA agonists and sedatives are all used. The NCCU staff will be well versed in treating this condition and can offer advice for patients outside the NCCU setting. Educating and supporting the patient’s family is very important as these events look very alarming and they may fear that an irreversible deterioration has taken place. Blackman JA, Patrick PD, Buck ML, Rust RS, ‘Paroxysmal autonomic instability with dystonia after brain injury’, Arch Neurol (2005); 61: 321–328 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Traumatic brain injury 08.c.iv • Disorders of consciousness (DOC) After severe traumatic brain injury a small number of patients fail to wake up despite withdrawal of sedation. Rarely, they may be in a persistent coma, or be locked in. Others (6% of those admitted with severe TBI in one study from 1970s) develop a prolonged disorder of consciousness where there is wakefulness without awareness. This has been described as a vegetative state (Jennet and Plum, 1972); this term has replaced ‘apallic syndrome, total dementia, akinetic mutism’. To make this diagnosis, any persisting effects of medication, metabolic disturbance, or other complications such as hydrocephalus have to be excluded and the patient should be assessed repeatedly by clinicians experienced in managing patients with this condition. Patients in a vegetative state (VS) demonstrate: • sleep wake cycle • ‘no evidence of awareness or self or environment at any time’ •no responses to visual, auditory, or noxious stimuli ‘of a kind suggesting volition or conscious purpose’ • no evidence of language comprehension or meaningful expression The minimally conscious state (MCS) Some patients will demonstrate severely altered consciousness but have some very limited awareness where there is minimal but definite behavioural evidence of self or environment. This condition was first described as the minimally conscious state by Giacino in 2002. Before making any diagnosis of VS or MCS it is imperative to exclude reversible causes of the lack of behavioural response to environmental stimuli. Assessment should be repeated on several occasions and include a thorough neurological as well as general examination looking for signs of raised intracranial pressure or infection, paying particular attention to eye movements, blink responses to visual threat, other cranial nerves and checking spinal reflexes to ensure there is no critical illness neuropathy or spinal cord injury preventing peripheral responses. Investigations These will be guided by the history and management to date but might include: •repeat CT brain scan to exclude hydrocephalus or re-bleeding or rarer problems such as ‘syndrome of the trephined’ •MRI of the brain may show areas of diffuse axonal injury and brain stem damage more clearly • EEG to exclude subclinical seizures • bloods to exclude hypercapnia, hypoglycaemia, hyponatraemia, hypopituitarism Management The same management principles apply to this patient group as they do with any other unconscious patient. The key additional point to emphasise to staff is that the patient may be able to understand them. Optimal postural and pain management is also crucial (both in long term but also before confirming a diagnosis of VS). Patients are often more responsive when sat out but may need gradual adjustment to achieve this over many weeks. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 Assessment of the disorder of consciousness Before assessing a person’s level of awareness the following should be considered: •effect of sedating drugs, eg. baclofen – this patient group is generally more sensitive to the sedative effects of drugs so any sedating agent should be slowly withdrawn if possible before diagnostically labelling the person as in a vegetative state. 08 •effect of fatigue – people with a DOC fatigue very rapidly during assessment so these need to be kept short, eg. limited to 10–15 minutes only to ensure potential responses are not affected by fatigue. After specialist assessment and with specialist monitoring it may be helpful to consider a trial of alerting medication such as modafinil although there is limited evidence for long term benefit to date. Measuring any change Systematic assessment of the patient’s change in response to a range of stimuli is facilitated through the use of a range of formal measures which are designed to pick up small but meaningful differences that might denote an improvement in the patient’s level of consciousness over time. 1.Coma Recovery Score (CRS) (Giacino et al, 2002) most straight forward and useable by whole team 2.Wessex head injury matrix. (WHIM) (Shiel et al,2000) • documents recovery from coma to end of PTA References The Vegetative State: guidance on diagnosis and management, Report of a working party of the Royal College of Physicians (2003), (currently being reviewed by a joint working party for the British Society of Rehabilitation Medicine and RCP) Giacino JT, Ashwal S, Childs N, Cranford R, Jennett B, Katz DI, Kelly JP, Rosenberg JH, Whyte J, Zafonte RD and Zasler ND, ‘The minimally conscious state: Definition and diagnostic criteria’, Neurology (2002); 58 (3): 349–353 Shiel A, Horn S, Wilson BA, McLellan DL, Watson M and Campbell M, ‘The Wessex Head Injury Matrix main scale: A preliminary report on a scale to assess and monitor patients recovery after severe head injury’, Clinical Rehabil (2000); 14: 408–416 Western Neuro Sensory Stimulation Profile (WNSSP) Gill-Thwaites H, ‘The Sensory Modality Assessment Rehabilitation Technique – a tool for Assessment and treatment of patients with severe brain injury in a vegetative state’, Brain Injury (1997); 11 (10): 723–734 • correlates with FIM/FAM • observed or elicited behaviours • training required 3.Sensory, modality assessment rehabilitation technique (SMART) assessment (Gill-Thwaites et al, 1997) •ten repeated detailed assessments of reactions to sensory stimuli in many domains over a period of three weeks • training required Research tools Various research groups have designed Funchonal MRI (fMRI) and electrophysiological paradigms to explore whether this group of patients have any covert awareness but none of these is ready for widespread clinical use at present. Prognosis It is best to avoid being drawn in to making firm predictions about recovery in the first few months as there are few reliable predictors of outcome other than age. While the prognosis is grave with very few recovering to full independence it is worth considering that a number of European studies have documented up to 20% significant recovery including return to work in cohorts of patients described as in a vegetative state at one month post injury. A report by a multi society task force in the USA has indicated that if a person remains in a vegetative state after four years then the mean survival is 12.5 years. Further discussions with the family including withdrawal of artificial nutrition and hydration are beyond the scope of this manual and should only be embarked upon if the family request it; once there is no further sign of change; once all the treatable causes have been actively excluded; and after a full assessment has been completed by experienced clinicians. The timing of such discussion remains debateable but current RCP guidelines indicate that in England it is not appropriate to consider for at least 12 months after traumatic brain injury and that it is a matter for the High Court to advise on every such case where withdrawal of artificial nutrition and hydration is being considered. If an advance directive has been made this should be discussed with the family and the hospital legal team to ensure that it is valid in the circumstances before acting as it directs. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Traumatic brain injury 08.c.v • Mood and cognition assessment 08 Assessment of cognitive function in a patient with brain injury is essential and will need repeating as recovery occurs. All members of the multi-disciplinary team should be able to perform basic cognitive assessment as this will inform the approach to the rehabilitation of the patient. Clinical management issues to consider •Assess the patient in a quiet area, preferably after a period of rest, away from distractions. •Take into account drugs that may affect cognitive functioning, eg. opiates, anticholinergic drugs (eg. bladder stabilisers such as oxybutinin), anti-epileptic drugs. • establish pre-morbid handedness • establish pre-morbid functioning • assess for post-traumatic amnesia • assess for post traumatic stress disorder Cognitive domains to assess: •memory • attention and concentration • speech, language and communication skills • visuospatial and constructional skills • executive functioning • mood, personality and behaviour For a more comprehensive assessment of mood and cognition refer to psychology. Outcome measures/ assessment tools • Addenbrooke’s Cognitive Examination – 111 (publication pending) • Wimbledon Self-report Scale References Royal College of Physicians and British Society of Rehabilitation Medicine, Rehabilitation following acquired brain injury: national clinical guidelines, (Turner-Stokes L, ed) London: RCP, BSRM (2003) ‘Biopsychosocial approaches in neurorehabilitation: Assessment and management of neuropsychiatric, mood and behavioural disorders’, Neuropsychol Rehabil (2003); 13 (4) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Traumatic brain injury 08 Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services 08.c.vi • Behavioural management guidelines These guidelines are intended to provide useful information for staff working with patients who have cognitive deficits and who may present with challenging behaviour. Staff should find them particularly helpful for patients in the first few weeks of their admission to the ward, when problems are more severe. They are designed to provide useful background information to help staff understand the patient’s difficulties and behaviour and then to offer practical guidance in terms of management. Suggestions for management may focus on things the team needs to do, things staff can ask relatives/carers to do, and changes which could be made to the patient’s environment. It is important to remember when seeking to change behaviour that consistency of approach is vital. Therefore all staff working with the patient need to be aware of the guidelines and use them every time they interact with the patient. These guidelines have been written for staff. There may be information which staff feel it would be useful for relatives/carers to know and it is intended that in such cases this information would be discussed with the relatives / carers by a member of the team, rather than simply being given to them. If a member of staff wishes to give a relative or carer a copy of any of these guidelines, this should only be done with the agreement of a psychologist (if available) or occupational therapist (OT) who knows the patient. Further help in managing this patient group Managing patients with neuro-behavioural disorder in an acute setting can be very challenging. For patients being treated outside of the Major Trauma Centre, please flag up any behavioural problems with your Trauma Link who can contact the Network Co-ordination Service for further advice. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Traumatic brain injury 08.c.vi • Behavioural management guidelines: post traumatic amnesia (PTA) Everyday memory and general functioning is disrupted. Presentation In the early stages after brain injury the person may still be in PTA. PTA is a phase marked by sometimes severe confusion/disorientation associated with memory loss for some events immediately before the injury and memory loss for events since the injury. Therefore, although the person may be conscious and responsive their everyday memory is not working at all. This is because their brain function is so disrupted that they are unable to lay down new memories. The person may be agitated and/or aggressive, which may be related to the bewilderment he or she often feels due to being unable to always remember what has happened. •The person may be unable to work out what is happening to them and thus become frightened and/or agitated. Their behaviour may appear bizarre and they might become fixed on an idea, eg. they firmly believe that they have to get to a meeting, or that the hospital is a hotel or a prison. •It may take some weeks for the person to remember important information, eg. they are in hospital; they have had a brain injury; who people are. •The person is often disorientated in time, ie. not remembering the day of the week, month or year. •The person may have great difficulty in finding their way around the unit and they may wander, putting them at risk. •In the first few weeks the person will tire easily doing very simple things and will only be able to concentrate on what you are saying or doing for very short periods. The duration of PTA is linked with the severity of the head injury. The longer the period of PTA, the more severe the head injury, with PTA lasting more than seven days being considered representative of a severe head injury. PTA can last from hours to days to weeks and is a difficult period to manage. If the period of PTA is prolonged, consideration should be given to transferring the patient to a specialist neuro-behavioural environment (see Directory of Services and seek advice via the Network Co-ordination Service). Attention In the early stages of recovery following a brain injury the person will often have difficulty with many aspects of attentional function. Therefore he or she may only be able to concentrate or focus on something for very short periods of time. He or she may also have difficulty in attending to more than one thing at a time. There may also be difficulties in switching from one task to another. This often improves quickly over the first few weeks. It will be necessary to keep any instructions you give the person very short and concise. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services 08 Clinical management issues to consider Team • Try and organise a single room for the patient. •For the first week or two following admission the person should not be permitted to leave the ward unless accompanied by a member of staff (consider Deprivation of Liberty (DOL)). If confusion and/or disorientation is severe and the person presents a risk, eg. wandering, it may be necessary to provide ‘specialing’ to reduce risk. 08 • General communication: Do: – remain calm at all times during communication – expect to have to repeat yourself time and time again –use an errorless learning approach, ie. give the patient correct biographical and situational information Don’t: –become frustrated with patient or with lack of progress – this phase is usually shortlived (days) but can last for weeks –try and test the patient’s memory or orientation unless performing a formal cognitive assessment •Orientation: An orientation kit consisting of a board with cards giving current information (year, month, date, day of the week, name of hospital) should be put on the person’s wall in their room and the person should have their attention directed to it frequently during the day. Encourage visitors to do the same. As the person improves they can be encouraged to change the cards on the boards themselves. •Programme: A large copy of the person’s weekly programme will be put on their wall. Attention should be drawn to it frequently throughout the day to assist with orientation, eg. what the person is doing next. As the person gradually improves, encourage them to refer to the programme each day themselves. Outcome measures/ assessment tools • perform risk assessment regarding risk to self or others, including risk of absconding • Westmead PTA Scale •seek specialist advice •Overstimulation: Balance the need for a regular programme of activities with the person’s need for lots of rest at this stage. If the person is in PTA or does have significant attentional problems, this may mean that therapy sessions will be very short at first. Cognitive assessment should be kept to a minimum, but if any longer than 20 minutes should be conducted in stages over several days. Make use of bed rest or ‘quiet time’ at regular intervals and especially if the person is upset or agitated. Family and visitors References • Write a simple account of the accident which led to the hospital admission. Rehabilitation following acquired brain injury: national clinical guidelines, BSRM & RCP (2003) • Keep a diary in the room for visitors to use. They can record simple information, eg. who visited and when, what was done or talked about. Delirium: diagnosis, prevention and management (NICE, July 2010) (same principles apply) • Ensure visitors do not try to ‘test’ their relative by asking lots of questions. At this early stage it is much better to just give information, rather than expect them to remember it. • Ask visitors to leave some photographs of people/pets/home with labels underneath. Post Traumatic Amnesia factsheet, www.headway.org.uk Good practice & clinical guidelines Seek specialist advice via Network Co-ordination Service TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Traumatic brain injury 08.c.vi • Behavioural management guidelines: agitation Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services Brain injured people at an early stage of recovery tend to have a very low tolerance for frustration and fatigue, eg. if you are late, if they cannot do something easily or if they need a break. When first admitted to hospital it is common for many patients to go through a stage of agitation, maybe because the environment is new and unfamiliar to them and they are struggling to adjust to their situation. They could be worried about physical or cognitive changes or simply desperate to get home and concerned about their future. In particular, cognitive changes may make it difficult for the person to be aware of and control their agitation. As time progresses and the person adjusts to their environment and their situation and begins to make relationships on the ward, agitation generally decreases. Clinical management issues to consider •Consider the potential for the presentation being due to drug or alcohol withdrawal or other medical factors. •Remember brain injury patients are very sensitive to the psycho-active properties of drugs. Team •Remember that the person may not recognise that they are beginning to become agitated and it is therefore necessary for you to take the lead. •If the person becomes agitated find out why if you can. Try to calm them down, eg. by reminding them why they are in hospital. If the agitation does not reduce, distract the person’s attention to something else or if it is safe to do so leave them to be alone for a short period. •Try to keep the environment as quiet as possible and encourage the person to have rests at regular intervals. •Structure the person’s day to balance stimulation and relaxation. Remind the person about what they are meant to be doing and when, as routine can provide familiarity and reassurance. •Try not to take the person’s behaviour personally. It is important to be calm and speak quietly. The person cannot control the way they are behaving at this early stage. •When the person has calmed down they are often apologetic. Use this opportunity to reinforce information you want them to learn, eg. ‘you tend to get worked up because you have had a brain injury’. Family and visitors • Try to encourage only one or two visitors at any one time. •At the early stage visitors should be limited to several people the person knows really well. It is often useful to agree who these people will be with a key family member (if other visitors arrive unannounced it may be necessary to refuse access with appropriate explanation). •Discourage visitors from questioning or testing the person about what they can remember or do. Avoid direct confrontation as much as possible. •Early on, visits should be kept short, in some cases as short as 15–20 minutes if the person gets very agitated. Try to ensure visitors keep to this even if the person seems to be coping well. It is better to end the visit on a good note. •If the person becomes agitated before the normal end of the visit, try to calm down and distract them onto another topic of conversation or onto another activity, eg. by taking them for a walk. It may be necessary to leave earlier than planned. Remind relatives that the person will have good and bad days. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Outcome measures/ assessment tools • Agitated Behaviour Scale (ABS) • Antecedent, Behaviour, Consequence (ABC) chart • perform risk assessment • seek specialist advice Good practice & clinical guidelines Seek specialist advice via Network Co-ordination Service 08 08 • Rehabilitation Traumatic brain injury 08.c.vi • Behavioural management guidelines: disinhibition Early in recovery after brain injury disinhibition may result because the person lacks full control of their behaviour, being unable to distinguish between socially appropriate and inappropriate behaviour. This is often a result of frontal brain injury, particularly the orbito-frontal regions. Presentation •Over-familiarity, eg. willingness to divulge too much personal information or where the person expects staff or other patients to divulge too much personal information. •Using language that the person would not normally use in this setting, eg. swearing. • Inappropriate sexual behaviour, eg. inappropriate sexual remarks or advances. • Laughing inappropriately or silliness. Clinical management issues to consider It is important to be aware of certain factors either internal or external which may be acting to trigger inappropriate behaviour. Thus, if the person is over-tired, bored, or over-stimulated, these are examples of internal factors which may be influencing their behaviour. Examples of external factors which can trigger inappropriate behaviour are noise, other patients, a change in routine, or being asked to do something they do not want to do, or find difficult to do. It is therefore necessary when trying to change behaviour to consider all of these factors and change them where possible, eg. moving the person to a single room, or giving them shorter therapy sessions. Disinhibited or inappropriate behaviour can be very upsetting and even frightening to family members or in some cases may cause the family to become angry themselves. It is therefore essential for the team to explain to the family what is causing the behaviour and advise them on simple ways of dealing with it. This may include things like leaving the person if they become agitated to go and have a drink or even cutting a visit short and trying again later. Discourage When behaviour is inappropriate calmly but firmly discourage the inappropriate behaviour immediately. When inappropriate behaviour is more subtle or in a group situation you can try to ignore it and distract the person onto something else. Feedback Give the person immediate feedback about the inappropriate behaviour. Be very specific about what aspects of the person’s behaviour is inappropriate and why, eg. if the person is undressing in public you could say: “This is not the time nor place for taking your clothes off”. Explain the need for privacy or the possibility of offending others. Be aware that the person may be unaware of when they are behaving inappropriately or how bad it is. Often after brain damage people have problems with monitoring their behaviour. Often, providing regular feedback can itself be enough to trigger improvement. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services 08 Coach Encourage the person to behave appropriately by encouraging the behaviour you consider appropriate for the situation, eg. “In a group of people it is polite not to shout. People will listen better if you speak calmly.”. Praise the person when they manage to behave or interact appropriately and provide a reward if possible, eg. a drink, a walk in the garden, etc. 08 Due to cognitive problems such as poor attention or poor memory, be prepared to repeat yourself often. Changing behaviour takes time! Redirect After providing constructive feedback and coaching, redirect the person in order to re-focus their attention on the activity they were engaged in before the inappropriate behaviour occurred. If the person was not actively doing something before find something for them to do. Outcome measures/ assessment tools • perform risk assessment to clarify level of risk to self and others. If risk demonstrated, seek specialist advice Good practice & clinical guidelines Seek specialist advice via Network Co-ordination Service TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Traumatic brain injury 08.c.vi • Behavioural management guidelines: confabulation Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services Confabulation has been defined as ‘a falsification of memory occurring in clear consciousness in association with an organically derived amnesia’ (Berlyne, 1972). Confabulation manifests after brain trauma particularly when there is a combination of memory loss and frontal lobe injury. Confabulation is usually temporary but may in some cases continue to be a long term problem. Examples of confabulation • Bizarre explanations about how the accident happened. • Getting information or details of conversations mixed up. • Talking with conviction about something which did not happen. Clinical management issues to consider •Never encourage or reinforce inaccurate information. Calmly but firmly correct the information, eg. ‘This is what did happen or this is what we talked about’. •Some people will become agitated or confrontational when corrected. After giving correct information distract their attention onto something else. • Provide explanation to family about why confabulation occurs. •Encourage family and friends not to ask the person to explain why they believe what they have said. This simply results in confrontation or long tiring explanations and reinforces the incorrect information. Advise them to correct the person quickly but in a kind and matter of fact way. Outcome measures/ assessment tools • perform risk assessment to clarify level of risk to self and others. If risk demonstrated, seek specialist advice. Good practice & clinical guidelines Seek specialist advice via Network Co-ordination Service TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 08 • Rehabilitation Traumatic brain injury 08 Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services 08.c.vi • Behavioural management guidelines: perseveration This refers both to: •Perseveration of ideas: where the person is unable to move onto another topic of conversation, returning to the same theme repeatedly. •Perseveration of behaviour: where the person repeats the same action and is unable to break the cycle without help, resulting in them repeating the same mistakes. Clinical management issues to consider Perseveration of ideas Signal to the person that you are going to change the topic so they can try to clear their mind and concentrate on a new topic. Move on, but be prepared to give a reminder that you are now talking about something else, eg. ‘No we are going to talk about this (whatever it is) now’. Perseveration of behaviour It can be helpful to model what you want the person to do instead. If this does not work after a few tries it is better to take a break. Try not to allow the person to become agitated as this can make things worse. With family Explain to the family why the person is so repetitive in their conversation or behaviour as otherwise the behaviour can be irritating or seen as being ‘difficult’. Outcome measures/ assessment tools • seek specialist advice Good practice & clinical guidelines Seek specialist advice via Network Co-ordination Service TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Traumatic brain injury 08.c.vi • Behavioural management guidelines: lack of insight/denial Impaired insight is a common feature of frontal brain injury. •Impaired insight usually improves over time as the person becomes more aware of their limitations. However, in some cases development of insight will be part of a longer process and may require specific intervention. •People with brain injuries, whilst usually able to recognise physical disabilities often have difficulty in recognising and accepting changes in thinking and behaviour. •In order to behave appropriately in social situations we need insight. Insight enables us to predict and evaluate the effect of our behaviour on other people and allows us to imagine how they feel. •Lack of insight in the early stages is often due to the extent of disruption of normal brain function and is therefore related to the extent of the damage. •Lack of insight often causes difficulty because the person often refuses to accept their limitations and may be reluctant to participate in rehabilitation seeing no need for it. It may therefore cause aggression. •Lack of insight may also reflect a psychological difficulty in accepting changes in oneself and one’s situation. In this case it is usually referred to as denial. Clinical management issues to consider •Give simple, repeated explanations of why the person needs to be in hospital. Likewise, give clear, simple and frequent explanations of why the person is unable or less able to do something. It may be useful to have the above explanations written down for the person. The whole team should be aware that the same information usually needs to be repeated many times until it ‘sinks in’. •The person may have an unrealistic view of what they are able to do, eg. going home, going to work. Be cautious about telling someone just that he or she cannot possibly do something now. Instead, set specific smaller goals that are realistic and emphasise the importance of achieving these first in order to reach the patient’s goal. This enables the person to feel that they are still making progress and helps them see the point of what you are working on. •If, after a clear explanation the person still continues to refuse to accept problems or the need for help it is usually better to change the subject or do something else. Long attempts to reason with the person will only result in agitation and stress. You can emphasise the need for rest and relaxation at this stage of recovery and if necessary, leave the person alone for a short time. •It may be useful to agree set goals with the person and begin working first on those which they are most motivated to achieve. If a person is repeatedly reluctant to work on something it may be necessary to switch to something else. •Alternate between working on things that the person finds difficult and things that s/he enjoys. •Involve relatives and friends in reminding the person about the reasons why we need to work on something. •Go slowly and initially set out to achieve small goals, eg. the person will spend 10 minutes in the agreed activity. This can be gradually increased as motivation improves. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services 08 •Assessments and functional tasks can be used as a means of demonstrating difficulties to the person. When a difficulty is encountered draw the person’s attention to it in a matter of fact way. Remember to emphasise progress made and potential for improvement, eg. if the person is doing some cooking and misses out a step, draw attention to it and try to work out with them why this happened (could this be due to a memory failure or not reading the whole recipe). 08 Outcome measures/ assessment tools Seek specialist advice Good practice & clinical guidelines Seek specialist advice via Network Co-ordination Service TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Traumatic brain injury 08.c.vi • Behavioural management guidelines: poor motivation and initiation Reproduced with permission of the Colman Centre for Specialist Rehabilitation Services Injury to the medial frontal regions of the brain is particularly associated with the presence of apathy. The apathy often has emotional, motor and cognitive dimensions and manifests as poor initiation and motivation. Poor initiation is a difficulty in getting started. Typically the person will not do much at all when left alone and will have difficulty in generating ideas about what they could do. The person appears to lack motivation and/or interest in engaging in activities, but once started on activities may persist and enjoy them. Poor initiation and motivation can often be mistaken as laziness. In other cases poor initiation and motivation may reflect the person’s lack of insight or be associated with depression. It can also be because the person does not yet understand the goals of rehabilitation or the process involved. The person may also lack initiation but still be motivated to do some things, eg. he/she may be motivated to smoke but show poor initiation for getting washed and dressed. This is due to different areas of the brain being damaged. Clinical management issues to consider Before tackling these problems it is important (if possible) to identify which of the above factors are involved. Depression If there is reason to think that the person may be depressed it is important to first address this by asking the doctor or psychologist to carry out a specific mood assessment. Management may then involve medication and/or psychological intervention. Frontal lobe damage In this situation it is often necessary for the therapist / nurse to take the lead. Ensuring that the person has a clear structure to the day is important in improving initiation as it allows the patient to experience repetition of a task, which makes learning easier. Possible strategies •Provide opportunities for the person to engage in activities. Try to find out what the person might want to do and do not expect them to be able to choose between lots of different options. Provide two options for them to choose from. •Provide structure for the day, eg. in the programme and be prepared to give lots of encouragement, prompting and reinforcement. •Make use of timers and alarms to alert the person as to when an activity is about to start or when they are expected at therapy. •Make relatives aware of the reasons for poor initiation/motivation as otherwise the behaviour can be upsetting or misinterpreted as laziness or lack of interest. Outcome measures/ assessment tools Seek specialist advice Good practice & clinical guidelines Seek specialist advice via Network Co-ordination Service TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 08 • Rehabilitation 08.d • Spinal cord injury (SCI) Spinal cord injury refers to injury to the cord itself, whether this is complete or incomplete, and not simply a bony fracture of the spinal column. With spinal cord injury there may or may not be accompanying bony fracture or dislocation, and there will be a degree of neurological loss (of function). Clinical management • Involve physiotherapists immediately – particularly for chest management. • Undertake accurate pre (and post) surgery American Spinal Injuries Association (ASIA) scoring. In the early stages of rehabilitation consider management of: • chest / airway / breathing • Autonomic dysreflexia (AD) – see 8.d.ii • Poikilothermia* • bladder – see 8.d.iii 08 * Poikilothermia – a term used to describe the fact that spinal cord injury affects a person´s ability to control their body temperature. Instead, the paralysed body adopts the temperature of the local environment. Poikilothermia occurs in patients with lesion above T1. † Orthostatic postural hypotension – this occurs when there is an inability for the circulatory system to adapt to moving to an upright position. When an individual sits with the legs lowered, the body’s blood pools in the lower extremities. Blood pressure drops and the individual feels dizzy, light-headed or like they are going to faint. Rising slower will help, but elastic stockings and an elastic abdominal binder are necessary to assist the body with blood circulation. • bowel – see 8.d.iv • pressure area care • spasticity, spasm and posture management, including splinting • orthostatic postural hypotension† • neuropathic pain • nutrition, including swallowing • psychological support Other actions • Make referrals to the patient’s local area wheelchair services. • Commence application for continuing healthcare (CHC) eligibility if appropriate (and patient consents). • Refer to patient’s home area social services (if patient consents). • Liaise with Spinal Injuries Association (SIA) peer support workers for support visits. • Liaise with Department of Work and Pensions (DWP) advisor and legal services advisor as per patient/relatives wishes. References The Initial Management of Patients with Spinal Cord Injuries (National Spinal Cord Injury Strategy Board Working Party, 2012) [draft – unpublished] Management of People with Spinal Cord Injury (NHS Clinical Advisory Groups Report, 2011) Standards for Patients Requiring Spinal Cord Injury Care, Service Standards – Revised (South of England Spinal Cord Injury Board, 2010) Chronic Spinal Cord Injury: Management of Patients in Acute Hospital Settings (RCP, 2008) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08.d.i • Spinal cord injury (SCI) Pathway 08 HOSPITAL & INPATIENT SERVICES COMMUNITY & OUTPATIENT SERVICES Spinal cord injury Advice, information and advocacy Code 110 Case management Code 140 Equipment/ assistive technology Code 135 Mobility/ transport Code 130 Voluntary activity Code 125 Community activity Code 120 Support at home/in the community Code 115 Trauma Unit Emergency Department Code 15 Major Trauma Centre Emergency Department Code 10 Trauma unit active participation rehab Code 40 Rapid access acute rehabilitation (RAAR) Code 30 Major Trauma Centre active participation rehab Code 40 Spinal Cord Injury Centre Code 25 Trauma Unit Code 15 Major Trauma Centre Code 10 Acute supportive rehab (ventilated) Code 20 Acute participation rehab Code 40 Slow stream rehab Code 60 Home Transitional rehabilitative accommodation Code 75 Specialist nursing homes (ventilated) Code 105 Community rehab Code 70 Spinal cord injury centre outpatient clinic Code 85 Trauma Unit outpatient Code 86 Vocational rehab Code 90 Psychological rehab Code 80 Lifelong maintenance rehab Code 100 Please refer to the East of England Trauma Network Directory of Services (DOS) for full code descriptions Based on the model developed by the Eastern Head Injury Group; Pickard, Seeley, Kirker et al, Journal of the Royal Society of Medicine (August 2004) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Spinal cord injury (SCI) 08 08.d.ii • Autonomic dysreflexia (AD) AD is a sudden and potentially lethal surge of blood pressure and it is often triggered by acute pain or a harmful stimulus. It is unique to spinal cord injuries and affects spinal cord injured people with lesions at or above T6. It can cause an extreme hypertension and can lead to cerebral haemorrhage and even death. It should always be treated as a medical emergency. Examples of typical triggers are: a full bladder, a full rectum, and an in-growing toenail. AD can occur at any time following the onset of spinal cord injury and spinal cord injured people with incomplete lesions are just as likely to experience autonomic dysreflexia as people with complete lesions, although (it is reported that) symptoms are less severe with incomplete lesions. AD occurs without warning in response to a painful or noxious, stimulus below the level of spinal cord lesion. This stimulus causes reflex sympathetic over-activity below level of cord lesion, leading to vasoconstriction and systemic hypertension. The hypertension stimulates the carotid and aortic baroreceptors leading to increased vagal tone and bradycardia. Peripheral vasodilatation, which would normally relieve the hypertension, cannot occur because of the injured cord. Blood pressure continues to rise until the cause is removed. (NSCISB, 2012) A patient with potential for AD should be issued with an AD card, which is available from the Spinal Injury Association (SIA). Signs and symptoms of AD The below list of symptoms is not exclusive. Patients may experience one, all or none of these symptoms: • pounding headache • hypertension (significant rise from patient’s normal baseline) • blurred vision • pupil constriction • bradycardia (<60 beats per minute) • respiratory distress • nausea • nasal congestion • sweating above the level of injury • flushed (reddened) face • piloerection (goose pimples) • red blotches on the skin above level of spinal injury • cold, clammy skin below level of spinal injury • patient is restless or apprehensive TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network > Section 10.e Autonomic dysreflexia monitoring tool Clinical management Symptoms of autonomic dysreflexia (AD) 08 Check patient’s blood pressure to confirm diagnosis (blood pressure greater than 200/100 or 20–40mmHg higher than normal) Sit patient up – avoid lying down For patients with catheter: • empty catheter bag and note volume • check tubing not blocked/kinked • if catheter blocked remove and re-catheterise using lubricant containing lidocaine For patients without catheter: if bladder distended and patient unable to pass urine insert catheter using lubricant containing lidocaine If bladder distension excluded – gently examine per rectum: If faecal mass in rectum gently insert gloved finger (covered in lidocaine jelly) into rectum and remove. If symptoms persist or cause is unknown: Give nifedipine or glyceryl trintrate (GTN). In adults, place sublingually the contents of a 10mg sublingual nifedipine capsule or 1–2 GTN tablets. Repeat dose can be given after 20 minutes, if symptoms persist. Outcome measures/ assessment tools • blood pressure chart • stool chart • fluid balance chart • autonomic dysreflexia (AD) monitoring tool (see toolbox) If blood pressure remains high, then an IV hypotensive may be required: • hydralazine 20mg slowly or diazoxide 20mg bolus Continue to search for cause and monitor blood pressure. May require management on high dependency unit if persists. Reproduced from: Royal College of Physicians, British Society of Rehabilitation Medicine, Multidisciplinary Association of Spinal Cord Injury Professionals, British Association of Spinal Cord Injury Specialists, Spinal Injuries Association. Chronic spinal cord injury: management of patients in acute hospital settings: national guidelines. Concise Guidance to Good Practice series, No 9. London: RCP, 2008. Copyright © 2008 Royal College of Physicians. Reproduced with permission. References Autonomic Dysreflexia Factsheet (Spinal Injuries Association, 2007) Chronic Spinal Cord Injury: Management of Patients in Acute Hospital Settings (RCP, 2008) The Initial Management of Patients with Spinal Cord Injuries (National Spinal Cord Injury Strategy Board Working Party, 2012) [draft – unpublished] TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Spinal cord injury (SCI) 08 08.d.iii • Management of the neuropathic bladder Acute clinical management In the acute stage, urethral catheterisation is recommended, unless priapism* is present, whereby supra-pubic catheterisation should be performed. The catheter should initially be left on free drainage. * Priapism – presence of persistent erection Ongoing clinical management Urodynamic studies are recommended to inform ongoing bladder management. This gives a baseline prior to starting ongoing bladder management and checks for any abnormalities. Guidelines (EAU 2003) •Urodynamic investigation is necessary to document the (dys-)function of the lower urinary tract. •The recording of a bladder diary is highly advisable. • Free uroflowmetry and assessment of residual urine is mandatory before invasive urodynamics is planned. •Video urodynamics is the gold standard for invasive urodynamics in patients with neuropathic lower urinary tract dysfunction. Should this not be available, then a filling cystometry continuing into a pressure flow study should be performed. •A physiological filling rate and body-warm saline must be used. References Guidelines on Neurogenic Lower Urinary Tract Dysfunction (European Association of Urology, 2003) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Spinal cord injury (SCI) 08 08.d.iv • Management of the neuropathic bowel * Gastrocolic reflex – this is one of a number of physiological reflexes controlling the motility, or peristalsis, of the gastrointestinal tract. It involves an increase in motility of the colon in response to stretch in the stomach and byproducts of digestion in the small intestine. Thus, this reflex is responsible for the urge to defecate following a meal. The small intestine also shows a similar motility response. The gastrocolic reflex helps make room for more food. Clinical management Once daily: • (administer stimulant (oral) laxative 8–12 hours before planned care if necessary) • rectal stimulant suppository insertion • gastrocolic reflex* stimulated by hot drink • abdominal massage in the direction of the bowel motion (if trained to do so) • digital rectal examination (DRE), and digital removal of faeces (DRF) • single digital check to ensure rectum is empty after last stool passed References Guidelines for Management of Neurogenic Bowel Dysfunction after Spinal Cord Injury (Spinal Cord Injury Centres of the United Kingdom and Ireland, 2009) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Spinal cord injury (SCI) 08 08.d.v • Skin care A patient who has sustained a spinal cord injury (SCI) will have anaesthetic skin below the level of their injury, therefore development of severe pressure ulcers can occur quickly as the person would have no awareness that a problem is developing. The most common sign that a pressure sore is beginning is the appearance of a red area, or red spot on the skin. Ordinarily, redness should clear within 30 minutes after the pressure is released from the area. If the redness does not clear, a pressure sore has begun. Non-use of muscles around the bony prominences of the body (hips, heels and elbows, sacrum and ischium) leads to muscle loss (atrophy), adding to the risk of skin breakdown. Any skin breakdown would mean that even once healed, the area would remain vulnerable to further breakdown in the future. Most common areas where pressure sores occur on individuals with SCI Sacrum Ischium Trochanter Bony areas of foot Heel •The force of friction or shearing (the dragging movement of skin tissues across a surface), such as sliding in a bed or chair can cause blood vessels to stretch or bend, leading to pressure ulcers. •An abrasion can occur when pulling across a surface instead of lifting. •A bump or fall may cause damage to the skin that may not show up right away. • People with limited sensation are also prone to skin injuries from burns. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Pressure sores can be caused by clothing, braces, or hard objects that put pressure on the skin. For example, following removal of any splint, skin will need to be checked thoroughly for any abrasions or marks to the skin to reduce the risk of skin deterioration. Clinical management guidelines For pressure sore prevention: •Record the patient’s Waterlow score and MUST score on admission and monitor these weekly. •Ensure that the correct mattress is used on the bed, and the correct cushion if a wheelchair is used – this is guided by the Waterlow Score. •The Patient’s skin needs to be checked for pink/red marks or abrasions prior to them getting dressed each morning and again on their return to bed. •Encourage or assist the patient to relieve pressure whilst sitting up in wheelchair for 2 minutes every hour. •Keep the patient’s skin clean and dry. Wet skin can become soft, inflamed and is less resistant to damage – wash and dry skin right away after any bowel or bladder accident; change clothes if they become wet. • Use lotion instead of powder on skin. •Encourage the patient to eat a well-balanced diet. Foods high in protein, vitamins and minerals help skin stay healthy and heal more quickly. • Refer the patient to the dietician if indicated by the MUST score. •Encourage to patient to drink – drinking the recommended amount of fluids to help skin stay soft. For management if a pressure area develops: •The key action on noticing a pressure mark on the skin is to remove pressure from the area. Dependant on the location of the mark, this may necessitate a period of bed rest. However if an ulcer develops it could take months to heal, and many people with spinal cord injuries are hospitalised for lengthy periods due to skin breakdown. •Involve the Tissue Viability Nurse Specialist for advice on treatment or dressing of the area. • It is essential to follow a rigorous, rigid turning regime. • Reassess Waterlow and upgrade pressure relieving equipment as indicated. •Reassess MUST score and refer to dietician (if not previously indicated by MUST score). References Pressure Ulcer Risk Assessment and Prevention (NICE, 2001) European Pressure Ulcer Advisory Panel (EPUAP), Pressure Ulcer Prevention and Treatment Guidelines (1998), www.epuap.org 08.e.i • Pelvic injury Pathway 08 HOSPITAL & INPATIENT SERVICES Complex pelvic or acetabular fracture COMMUNITY & OUTPATIENT SERVICES Trauma Unit Emergency Department Code 15 Oxford – John Radcliffe Trauma & Orthopaedics Code 20 John Radcliffe inpatient rehab Code 40 Major Trauma Centre Emergency Department Code 10 London – St George’s Trauma & Orthopaedics Code 20 St George’s inpatient rehab Code 40 Norwich – Norfolk & Norwich Trauma & Orthopaedics Code 20 Norfolk & Norwich inpatient rehab Code 40 Major Trauma Centre inpatient rehab Code 40 Major Trauma Centre Trauma & Orthopaedics Code 20 Trauma Unit local to patient’s home Code 40 Home Outpatient follow-up Code 85 Community rehabilitation Code 70 Please refer to the East of England Trauma Network Directory of Services (DOS) for full code descriptions Based on the model developed by the Eastern Head Injury Group; Pickard, Seeley, Kirker et al, Journal of the Royal Society of Medicine (August 2004) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation Pelvic injury 08.e.ii • Pelvic and acetabular injuries rehabilitation guidance Pelvic injuries are more common in patients with multiple trauma. It can involve the soft tissues as well as pelvic fractures, especially in high velocity injuries. Clinical management issues to consider Obtain knowledge regarding: 1.mechanism of injury 2.type of soft tissue injury / fracture: •genito-urinary •gastro-intestinal •neurological • pelvic fracture: –acetabular – stable pelvic ring fracture – anterior or posterior – unstable pelvic ring fracture – anterior or posterior 3.orthopaedic / urology / gynaecology / gastro-intestinal treatment received: • review X-rays / CT scans / MRI scans • review operation reports if applicable •discuss with surgeons details of operative findings and follow-up imaging required 4.normal course of healing for that injury / fracture, complications and expected outcomes Acute stage management principles: 1.pain relief 2.monitor pulse, blood pressure and haemoglobin level 3.input / output charting including management of haematuria and urinary catheter (if urethral damage sustained) 4.consider paralytic ileus 5.document American Spinal Injuries Association (ASIA) score if neurological damage sustained Rehabilitation MDT goals: 1.pain relief: • pain relief ladder: paracetamol, NSAIDs, opiates 2.prevent complications 3.maintain / restore range of movement (ROM) of joints 4.muscle strengthening 5.personal care and gait retraining TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 Watch out for complications: 1.local: • blood vessel damage: monitor circulation •nerve damage: Please refer to spinal cord injury guidelines regarding bowel and bladder management. Consider urology and gastro-intestinal surgery input as indicated eg. stoma care 08 • stiffness of joints and muscle atrophy •wound infection – swab for culture and sensitivity (C&S) and start systemic antibiotics •pin site infection if an external fixator is used, swab for C&S and discuss with orthopaedic team starting systemic antibiotics • metal work loosening or damage • delayed union which can progress to non-union • malunion: monitor for fracture redisplacement • genito-urinary, eg: – urethral stricture if urethral trauma sustained –testicular haematoma 2.systemic: • deep vein thrombosis (DVT) / pulmonary embolism (PE) •anaemia • fat embolism •pneumonia • urinary tract infections •constipation • pressure sores Mobilisation: 1.Can be a progression from complete bed rest to assisted transfer activities, non-weight bearing ambulation, toe touch, partial weight-bearing, weightbearing as tolerated and finally full weight bearing. 2.There is no specific time for weight-bearing after a pelvic fracture. Decisions are in liaison with the orthopaedic team based on the type of fracture, type and quality of the fixation, bone condition, ability to control weight-bearing (eg. multiple injuries) and evidence of fracture healing. Outcome measures/ assessment tools • American Spinal Injuries Association Scale (ASIA) • Functional Independence Measure (FIM), assessment on admission and discharge Discharge planning •Ensure communication and follow-up with orthopaedic surgery, urology, gynaecology, gastro-intestinal surgery and rehabilitation medicine (including physiotherapy and occupational therapy) teams as applicable. •Make referrals to patients local area wheelchair services if applicable. References Brammer CM and Spires MC, Manual of Physical Medicine and Rehabilitation, Hanley & Belfus Inc, PA (2002) O’Young BJ, Young MA and Steins SA, Physical Medicine and Rehabilitation Secrets, 3rd Ed, Mosby Elsevier, PA (2008) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation 08.f • Traumatic limb loss: management guidance 08 Trauma accounts for 20–25% of lower limb amputations, while it is the most common cause of upper extremity amputations. Amputations can occur at different levels, details of which are beyond the scope of these guidelines. Please find below some general considerations. Clinical management issues to consider Involve rehabilitation team prior to surgery to discuss stump length and type if required • date, level and cause of amputation • details and recommendations of surgical team involved • potential complications – tissue viability, infection etc • removal of drains, date for removal of clips / stitches • documentation of neurovascular status of limbs •plan for review of stump wound plus change of dressings – soft vs rigid, vac dressings •documentation of fractures plus review of X-rays with potential impact on mobility • current management of stump and phantom pain Throughout admission • monitor stump wound healing • control stump volume, eg. Juzo® shrinking sock •clarify with the trauma team regarding weight bearing status, the management and monitoring of other associated injuries if applicable • monitor nutrition (use weight chart and MUST scoring chart) • identify if there is a need for psychological support •physiotherapy involvement – maintenance of range of movement (ROM) of joints of amputated limb (prevent contractures) plus strengthening exercises, aerobic conditioning, mobilisation (eg. P-PAM aid/Femurette) and balance training with consideration of other injuries / issues •OT involvement regarding personal care and assessment for provision of wheel chair if applicable Discharge planning • OT access visit if applicable plus follow up plan including vocational aspect • make referral to patients local area wheelchair services if applicable • physiotherapy follow up plan • wound follow up if necessary • amputee primary clinic appointment Outcome measures/ assessment tools • weight chart • MUST scoring chart • Functional Independence Measure (FIM), assessment on admission and discharge References BSRM Amputee Rehabilitation: Recommended Standards & Guidelines (2nd edn), (October 2003) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08.f.i • Traumatic limb loss Pathway 08 HOSPITAL & INPATIENT SERVICES COMMUNITY & OUTPATIENT SERVICES Traumatic amputation Information & advocacy Code 110 Support at home / community Code 140 Voluntary & charity organisations Code 125 Mobility/ transport Code 130 Equipment and assistive technology Code 135 Case management Code 140 Outpatient rehabilitation (gait and prosthetic training, practice ADL and UL use) Code 85 Major Trauma Centre (part of complex trauma) Code 10 Amputation within the initial admission Rapid access acute rehabilitation Code 30 Trauma unit Code 15 & 40 Amputation performed during subsequent admissions (related to and within one year of the original trauma) Code 10/15 Referral to Amputee rehabilitation services (including pre-amputation consultation whenever possible) Community hospital rehabilitation Code 70 Psychological rehab Code 80 Specialist inpatient amputee rehabilitation unit Code 25 Vocational rehabilitation Code 90 Home Code 60 Pain management OPC Code 95 Transitional rehabilitative accommodation Code 75 Lifelong prosthetic maintenance Code 100 Please refer to the East of England Trauma Network Directory of Services (DOS) for full code descriptions Based on the model developed by the Eastern Head Injury Group; Pickard, Seeley, Kirker et al, Journal of the Royal Society of Medicine (August 2004) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation 08.g • Complex orthopaedic injuries: rehabilitation guidance Orthopaedic injuries incorporate a wide spectrum of injuries, from soft tissue injuries alone to complex fractures. These injuries may be multiple and have to be managed with knowledge of the patient’s pre-existing medical conditions, level of function as well as independence with an aim to restore pre-morbid status. Clinical management issues to consider Obtain knowledge regarding: 1.mechanism of injury 2.type of soft tissue injury / fracture 3.orthopaedic treatment received: • review X-rays / CT scans / MRI scans • review operation report if applicable •discuss details of operative findings with orthopaedic surgeon (eg. quality of fixation achieved and bone quality) as this can affect rehabilitation progression and timing, check X-rays 4.normal course of healing for that injury/fracture, complications and expected outcomes Acute stage management principles: PRICE P protection / pain relief R relative rest I ice C compression E elevation Rehabilitation MDT goals: 1.pain relief: • pain relief ladder: paracetamol, NSAIDs, opiates • consider analgesia prior to physiotherapy or OT session 2.correct deformity 3.protect injured tissue 4.prevent complications 5.restore range of movement (ROM) 6.muscle strengthening 7.personal care and ambulation retraining 8.consideration for investigation, prophylaxis or treatment of osteoporosis TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 Watch out for complications: 1.local: •nerve damage: consider nerve conduction studies +/- liaison with specialist orthopaedic or neurosurgery team 08 • blood vessel damage: monitor circulation and liaise with vascular surgery team •compartment syndrome: suspect this if patient complains of severe pain and paraesthesia of toes and fingers, inability to move toes and fingers and poor capillary refill. Liaise with orthopaedic team immediately as fasciotomies might be needed. • stiffness of joints and muscle atrophy •wound infection (especially in open fractures) – swab for culture and sensitivity (C&S) and start systemic antibiotics •pin site infection if an external fixator is used – swab for C&S and discuss with orthopaedic team starting systemic antibiotics • metal work loosening or damage • delayed union which can progress to non-union • malunion: monitor for fracture redisplacement, especially in – fractures involving both the radius and ulna –comminuted fractures –oblique fractures –fractures treated with a cast as this can become loose when swelling decreases 2.systemic: • deep vein thrombosis (DVT) / pulmonary embolism (PE) •anaemia • fat embolism •pneumonia • urinary tract infections •constipation • pressure sores Mobilisation: 1.Can be a progression from complete bed rest to assisted transfer activities, non-weight bearing ambulation, toe touch, partial weight-bearing, weightbearing as tolerated and finally full weight bearing. 2.Consider the need for a brace in, eg. spinal and knee injuries. Outcome measures/ assessment tools • Functional Independence Measure (FIM), assessment on admission and discharge References Brammer CM and Spires MC, Manual of Physical Medicine and Rehabilitation, Hanley & Belfus Inc, PA (2002) 3.There is no specific time for weight-bearing after a pelvic or lower limb fracture. Decisions are in liaison with the orthopaedic team based on the type of fracture, type and quality of the fixation, bone condition, ability to control weight-bearing (eg. multiple injuries) and evidence of fracture healing. Discharge planning •Ensure communication and follow-up with orthopaedic surgery, vascular urgery, neurosurgery and rehabilitation medicine (including physiotherapy and occupational therapy) teams as applicable. • Make referral to patient’s local area wheelchair services if applicable. O’Young BJ, Young MA and Steins SA, Physical Medicine and Rehabilitation Secrets, 3rd Ed, Mosby Elsevier, PA (2008) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation 08.h • Tracheostomy care guidance The goal of caring for a patient with a tracheostomy is to ensure that the airway is maintained at all times. Clinical management issues to consider • establish indication for tracheostomy and patency of upper airway • note date of tracheostomy insertion • note size of tracheostomy tube • inspect tracheostomy site •ensure that equipment required (including tracheostomy safety box) is at the bedside and accompanies the patient if transferred off the ward Daily care interventions to ensure the patency of the tracheostomy tube Humidification Breathing through a tracheostomy bypasses the normal warming, filtering and humidification of inspired air. All tracheostomy patients will require a form of artificial humidification. • Deliver heated circuit humidification to immediately post-operative neck breathers. •Assess humidification effectiveness by observing tenacity of secretions and ease at coughing and clearing secretions. •Effective humidification will allow loose secretions to be easily cleared on coughing or suction. Nebuliser • ensure that humidified oxygen and nebulisers are prescribed • dispense one 5ml saline ampoule into nebuliser chamber •ensure tracheostomy mask is clean, place mask over tracheostomy tube and secure • turn on, ampoule will take approx 5–10 mins to disperse • when finished turn off, remove and dry mask with paper towel •saline nebuliser should be used 4–6 hourly. However, if secretions are dry nebulisers can be increased in frequency to 2 hourly to loosen and moisten secretions. If dry secretions persist contact tracheostomy nurse specialist • ensure patient is well hydrated if secretions remain thick • change nebuliser kits as per manufacturers’ guidelines Inner tube cleaning •remove tracheostomy aids, eg. speaking valve or Swedish nose / trachphone if being used •with one hand supporting the outer tube, remove the inner tube using a curved downward motion •insert spare, clean inner tube with one hand supporting outer tube reinsert the inner tube using an upward curved motion •using the tracheostomy cleaning brush or swab, clean the inner tube with sterile water until no secretions remain • tap any excess water off tube and store in a clean pot • ensure tube has clicked into place TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 08.h • Tracheostomy care guidance • reapply tracheostomy aid if being used 08 •inner tube should be cleaned 2–4 hourly. However, frequency of cleaning should increase if required, eg. when secretions increase due to a cold or chest infection or if secretions are dry (if secretions become dry, humidification should be increased, ie. saline nebuliser (up to 2 hourly/5ml ampoule) • all tracheostomy care given should be recorded on the tracheostomy care chart •ensure patient has call bell, pen and paper or another aid to communicate with staff / relatives Suctioning • ensures suction apparatus is working and suction chamber is not full • suction pressure should be between 13.5 and 20kPa (100–150mmHg) • wear non-sterile gloves • connect suction catheter to suction tubing – see below Inner diameter of tracheostomy tube (mm) * I t is more appropriate to use a size 12 catheter as although it is slightly larger than ½ the diameter it is more effective for secretion removal. Suction catheter (NB: see manufacturers details to confirm) FG (mm) 10mm 14 (4.5) 9mm 14 (4) 8mm 12 (4) 7mm 12* (4) 6mm 10 (3.3) •insert suction catheter using a non-touch technique, to the length of the inner tube plus 1cm if patient able to cough, or to carina and draw back 1cm (1/3 of catheter length) if patient cannot cough. (See chart below.) For patients unable to cough (approx 16cm on uni-medical marked suction catheter) (approx 22cm for adjustable flange tube (Uni-Perc) Action Insert catheter to the depth of the carina or until resistance felt. Withdraw catheter 1cm and then apply suction Rationale Withdrawal of 1cm limits suction causing damage to the carina For patients able to cough (approx 11cm on uni-medical marked suction catheters) Action Insert suction catheter to the length of the tracheostomy tube plus 1cm Rationale Patients will cough on suctioning so therefore do not need deeper suctioning • occlude suction port with thumb to apply suction • remove suction catheter steadily, this should take no longer than 15 seconds •throw away used suction catheter and reattach new suction catheter if required for further suctioning •if there are any signs of infection, eg. thick, green smelly secretions that are difficult to clear, inform doctors or tracheostomy specialist nurse to assess further TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08.h • Tracheostomy care guidance Tracheostomy dressing •Remove dressing and clean around stoma site with normal saline and gauze, ensure that the flange of the tube is clean and any crusting removed. •Observe stoma site for signs of redness, sores or ulceration. (If any of these are visible inform the doctors or tracheostomy nurse specialist to assess further.) • Apply barrier cream around stoma site. •Reapply clean tracheostomy dressing. Dressing should be changed daily, however, if required change more frequently. Neck collar Liaise with Major Trauma Centre (MTC) consultant nurse specialist in tracheostomy care as required Contact: 01223 348679 or bleep 152-459 When removing the tracheostomy ties, two people will be required, one to hold the tube whilst tapes are removed to prevent accidental decannulation. •With one hand supporting the tube, carefully untie and remove the neck collar. Replace with a clean collar. •Ensure that only two fingers fit down the side of the collar. If the collar is too loose the tube can become displaced. •Collars should be changed daily. Where ventilatory support is required use ribbon tracheostomy ties. Monitoring •Baseline observations including oxygen saturation and respiratory rate are done at the required frequency •Monitor daily for signs of DOPE: displacement, obstruction, pneumothorax / neumonia, faulty equipment. Accidental decannulation DON’T PANIC! Once the tracheostomy tube has been in place for about five days the tract is well formed and will not suddenly close. • reassure the patient • call for medical help Ask the patient to breathe normally via their stoma while waiting for the doctor / anaesthetist. The stay suture (if present) or tracheal dilator may be used to help keep the stoma open if necessary. • stay with patient • prepare for insertion of the new tracheostomy tube • once replaced, tie the tube securely Check tube position by (a) asking the patient to inhale deeply – they should be able to do so easily and comfortably, and (b) place hand in front of the opening – you should feel the patient exhaling if in correct position. Weaning Tracheostomy weaning should be agreed by the Multi Disciplinary Team (MDT) and specific, individual care plans put in place by the Tracheostomy Nurse Specialist and Speech and Language Therapy (SLT). References • Addenbrooke’s Tracheostomy Care Guidelines • www.tracheostomy.org TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 08.i.i • Burns injury Pathway 08 HOSPITAL & INPATIENT SERVICES Major trauma burns Trauma Unit Emergency Department Major Trauma Centre Emergency Department COMMUNITY & OUTPATIENT SERVICES St Andrew’s Burns Centre, Broomfield Hospital, Chelmsford Code 20 and 40 Home Out-patient follow-up Code 85 Community rehabilitation Code 70 Please refer to the East of England Trauma Network Directory of Services (DOS) for full code descriptions Based on the model developed by the Eastern Head Injury Group; Pickard, Seeley, Kirker et al, Journal of the Royal Society of Medicine (August 2004) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation 08.i.ii • Burns rehabilitation guidance Modern burn care is a multistage process and can be divided into four phases. Rehabilitation begins from Day 1 as achieving optimal function is a goal that needs to be considered at all phases: • P hase 1 (Days 1–3): Initial evaluation and resuscitation. Evaluation of percentage and degree of burns (Rule of nines, Lund and Browder chart), other injuries (eg. airway) plus co-morbid conditions. Airway maintenance, accurate fluid resuscitation as well as Hb monitoring +/- blood transfusion is required. Specific wound dressings are usually required as advised by plastic surgery team. • Phase 2 (first few days post injury): Staged operations for wound excision/ debridement, cover and closure. • Phase 3: Definitive wound closure (including replacement of temporary wound covers) and reconstruction of high complexity areas such as the face and hands. • Phase 4: Reintegration Clinical management issues to consider In acute burn rehabilitation •Management is individualised by burn location, depth of injury, percentage of body surface injured, associated injuries (eg. airway, fractures), complications and patient’s previous functional level and health. •Burn patients with inhalation injuries may have a tracheostomy and are at risk of developing: –pneumonia – adult respiratory distress syndrome – multisystem organ failure. • Patients who suffered an electrical injury may be susceptible to: – myocardial necrosis (consider CK monitoring) – arrythmias (consider ECG monitoring) –peripheral and central nervous system complications (consider MRI scans, EMG studies etc). •Patients with burn injuries may be in a catabolic state (especially if burn injuries are >30% total body surface area (TBSA)). –Address nutritional needs. Dysphagia can be an issue. Early enteral feeding and dietician input is essential (daily caloric requirements for adults: 25kcal/kg plus 40kcal/1% TBSA burn/day). –Monitor for metabolic abnormalities and increased insulin resistance. Monitor FBC, electrolytes, LFTs and bone function tests, blood glucose and inflammatory markers (ESR, CRP). • consider and address sleep disturbances • consider psychology / psychiatric input as necessary – consider previous history – patient might suffer from post-traumatic stress disorder or depression •Promote wound healing (liaise with plastic surgery team / tissue viability nurse regarding appropriate dressings to use at every stage. Do not forget donor sites). •Prevent complications such as joint contractures, weakness, decreased endurance and loss of functional abilities. Heterotopic ossification is another complication but preventative management is controversial. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 > Section 10.b Burns Wound care principles • decrease pain • prevent infection • prevent and suppress scarring 08 • prevent contractures • prepare wounds for grafting if necessary Positioning principles • fundamental to prevent contractions and compression neuropathies • patients usually adopt positions of comfort namely flexion and adduction • keep tissues in an elongated state •ideally, positions of extension and abduction should be chosen but these need to individualised to the patient’s specific injuries Splinting principles •used to prevent joint contractures (eg. joints with overlying deep partial thickness or full thickness burns are at risk), maintain proper positioning and protect new skin grafts • should be done with functional goals in mind • can be done with off the shelf or custom made splints • a good splint: – is easy to don and doff – avoids pressure on bony prominences and nerves –is made of remoldable materials and can be modified according to the patient’s needs (review splinting as necessary) Outcome measures/ assessment tools • Rule of Nines • Lund and Browder chart • Functional Independence Measure (FIM), assessment on admission and discharge References Brammer CM and Spires MC, Manual of Physical Medicine and Rehabilitation, Hanley & Belfus Inc, PA (2002) Chan L, Harrast MA, Kowalske KJ, Matthews DJ, Ragnarsson KT and Stolp KA, Physical Medicine & Rehabilitation, 4th edn, Elsevier Saunders, PA (2011) O’Young BJ, Young MA and Steins SA, Physical Medicine and Rehabilitation Secrets, 3rd Ed, Mosby Elsevier, PA (2008) Sheridan RL and Meier RH, Burn Rehabilitation (2010), http://emedicine.medscape. com/article/318436overview [accessed on 29/02/12] – is compatible with wound dressings and topical medications – exercise principles • initial goal is to maintain range of movement (ROM) and strength •programme depends on stage of wound healing, skin graft status (if applicable) and patient’s participation ability. Consult plastic surgeon as necessary • stretching programme is indicated when there is loss of ROM • once ROM is achieved, active exercise is preferred • strengthening / endurance training should begin as tolerated • do not forget analgesia Early ambulation principles •maintains independence, balance, lower extremity ROM and decreases risk of DVT •if lower limb skin grafting is present, do not start ambulation until a stable circulation of the graft sites is established – discuss with plastic surgeon first •prior to walking, begin with dangling the lower extremities to assess if the graft tolerates the dependent position • discuss the use of compression with plastic surgeon • check the graft before and after dangling/walking •monitor for gait deviations which may be due to pain, focal or generalised weakness, contractures, impaired sensation/proprioception or central nervous system causes Discharge planning •Ensure plastic surgery, physiotherapy, OT, nursing and psychiatric / psychology follow-up as necessary. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation 08.j • Spasticity management guidance (spinal cord injury and traumatic brain injury) The technical definition is ‘velocity-dependent increased resistance to passive limb movement in people with upper motor neurone syndrome’ (Lance 1980). At a clinical level, there are two main contributing factors to resistance to movement in the context of limb spasticity following damage to the brain or spinal cord: • neurogenic component: overactive muscle contraction •biomechanical component: stiffening and shortening of the muscle and other soft tissues Harmful effects of spasticity include: •pain • difficulty with seating and posture •fatigue •contractures • pressure sores •deformity • distress and low mood • poor sleep patterns • reduced function and mobility • difficulty with self care and hygiene Spasticity is not always harmful. Patients with a combination of muscle weakness and spasticity may rely on the increased tone to maintain their posture and aid standing or walking. Clinical management issues to consider Prevention of aggravating factors: • pain or discomfort •constipation • infection (eg. urinary or respiratory tract infection, pressure sores etc.) • tight clothing or catheter bags • poor postural management 24-hour postural management programme •document range of movement (ROM) of arms and legs (can patient feed self, lay down straight and sit in a chair?) • consider a ‘tilt in space’ wheelchair if it facilitates early mobilisation Physical therapy aims • maintain muscle and soft tissue length across joints • facilitate care giving (passive functional improvements) •facilitate active control of any residual movements to allow for active participation in tasks (active functional improvements) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 Medical treatment (in conjunction with physical therapy) •consider whether the spasticity is actually harmful and what impact treatment will have in the patient’s functioning • consider pattern of spasticity: generalised, focal or multi-focal problems 08 • quantify spasticity using Modified Ashworth Scale A management strategy can be a combination. While formulating such strategy, consider: •the different medications (eg. baclofen, tizanidine, gabapentin) and strategies available and their potential uses. If spasticity is combined with neurogenic pain, consider gabapentin as first choice • mode of administration (pharmacology) and dosing / technique used • mechanism of action of treatment(s) chosen • side effects, precautions and potential complications Prevention of physical aggravating factors Management strategy team decision-making with patient Physical treatments (posture management, physiotherapy, splints) Medical treatments Treatment options Generalised spasticity Regional spasticity Multi-focal and focal spasticity Oral agents Intramuscular botulinum toxin phenol nerve / muscle blockade Intrathecal baclofen Intrathecal phenol Orthopaedic surgery Neurosurgery Outcome measures/ assessment tools • Modified Ashworth Scale References Spasticity in adults: management using botulinum toxin (National guidelines, February 2009) Management strategy for adults with spasticity (reproduced with permission from Spasticity in adults: management using botulinum toxin, National guidelines, Feb 2009) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation 08.k • Augmented nutrition (spinal cord injury and traumatic brain injury) 08 Clinical management issues to consider Enteral feeding is a method of maintaining hydration and nutrition for patients who are suffering from a disability that affects the ability to take in an adequate oral intake to maintain nutritional status. A feeding tube is passed directly into the patient’s stomach or small bowel and liquid nutrition is provided. The decision to insert a gastrostomy tube should be made via consultation between the patient, next-of-kin or power of attorney, doctor(s) and staff. Consideration should be given to any advance care planning. The health care team, patient and representatives should consider the possible benefits of treatment as well as any risks or contra-indications. Indications for a gastrostomy tube include: • intact GI tract but unable to consume sufficient calories to meet nutritional needs • impaired swallowing related to neurological conditions Common risks of tube feeding include: pain at the tube site, local infection, aspiration pneumonia, tube occlusion, nausea, vomiting, constipation and diarrhoea. (rxkinetics, 2012) Feeding regime Patients requiring enteral feeding should be assessed, by a dietician to determine the most appropriate formula and feeding regime. The dietician should aim to meet the patient’s specific nutritional requirements, minimise complications and maintain cost-efficiency. Feeding regimes are either continuous or intermittent. Continuous feeds are indicated for patients who are at a high risk of aspiration, have gastro-intestinal tolerance (eg. diarrhoea) or for small bowel feeding. Feeds are either delivered by bolus, gravity flow or using pump-control. Bolus feeds are administered over 5–10 minutes, usually via a syringe. Bolus administration has the advantage of being a quick administration technique and frees the patient from tube lines. Feeding formulas are made up of carbohydrate, protein, fat, minerals and vitamins including sodium and potassium; and fibre free water is also an important component and constitutes up to 85% of the formula. Selection of a formula type depends on the patient’s nutritional requirements, gastrointestinal function, and any special disease considerations. The most commonly used formula products are lactose-free. Enteral feeds can be administered using a ready-to-hang feeding system (‘closed system’), or decanted (‘open system’) into a feeding bag or syringe. Weekly or twice weekly weighing is more effective than daily weighing, which is influenced by variations in fluid balance. (NICE 2006) Outcome measures/ assessment tools • weight chart • malnutrition Universal Scoring Tool (MUST) References Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition (NICE guidance, 2006) Guidelines for the management for enteral tube feeding in adults (Clinical Resource Efficiency Support Team, 2004) Rxkinetics, Section 2 – Complications of enteral nutrition (2012), http:// www.rxkinetics.com/ tpntutorial/2_3.html [accessed 20/02/12] TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 08 • Rehabilitation 08.L • Paediatric rehabilitation guidance 08 General considerations •It is important to recognise that the parents are experts on their child. It is also important to acknowledge their need for information. The presence of families who are well informed and participating in care is beneficial to the recovery of the child. •In some instances the child may not be the only member of the family to be seriously injured. •Even when the family are physically unharmed, the psychological impact is widespread and long-lasting. •It is well recognised that children who suffer major trauma often have learning or behavioural difficulties and some come from dysfunctional families. Such parents may have poor coping mechanisms. This impacts on parents’ relationships with staff caring for the child and they will require additional resources to help these families. Clinical management issues to consider •It is essential that there is an identified lead consultant to co-ordinate care (likely to be a paediatrician), liaising with other paediatric experts as necessary, eg. other paediatricians, paediatric neurologists, neuropsychologists and paediatric (general / neuro / orthopaedic) surgeons. •Definitive planned surgery for amputations should be performed in consultation with the consultant in rehabilitation medicine and prosthetic services, allowing pre-amputation discussion with the child (if appropriate) and parents. •Neuropsychology services should be readily accessible for children and young people with traumatic brain injury, to assess the degree or neurological damage and its impact on learning, memory and mental health. Programmes should then be based on these assessments to improve function in these areas and to provide liaison with educational psychology services and local clinical psychology services for ongoing rehabilitation. •A Counsellor or social worker support should be available to liaise with and support families throughout the child’s pathway of care. Discharge planning • Re-integration is paramount for children following major trauma and traumatic brain injury. Early and regular contact should be made with the local paediatrician, general practitioner and community multidisciplinary team so they can be involved in planning the long-term care of the child from an early stage. This must be an inclusive process involving all services and health professionals involved in the child’s care. The rehabilitation team should advise on school needs and liaise with school services. • Essential rehabilitation equipment, including wheelchairs and mobility devices, should be made available as soon as possible. Outcome measures/ assessment tools • Glasgow Coma scale for Young Children • WeeFIM – is a measure of functional abilities and need for assistance associated with disability in children aged 6 months to 7 years. • COAT (Children’s Orientation and Amnesia Test) – designed for children recovering from TBI. It assesses general orientation, temporal orientation and memory. A score within two standard deviations (SD) of the mean for age defines the end of posttraumatic amnesia (PTA). References Management of children with major trauma (NHS Clinical Advisory Group Report, February 2011) TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 09 Major incidents – emergency preparedness 09 10 Toolbox 10 10.a.i • Trauma team checklist Before patient arrival: Trauma team activated: Time: H H : M M ADULT PAEDIATRIC OBSTETRIC PPE CT / radiology notified Resus bay equipment checked, eg: • ventilator • blood warmer/rapid infuser • venous access kit Required specialists contacted Drugs / infusions prepared, eg. TXA ED documentation started Massive blood loss activated Receptionist informed Briefing: ATMISTER Roles Aim Network Co-ordination Service: 0300 330 3999 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 10.a.ii • Trauma team roles Airway specialist NAME Airway assistant NAME Nurse 1 NAME Doctor 1 NAME Doctor 2 NAME Nurse 2 NAME Trauma team leader Scribe NAME NAME Network Co-ordination Service: 0300 330 3999 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 10 • Toolbox 10.b.i • Burns – Rule of Nines 10 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 10 • Toolbox 10.b.ii • Lund and Browder chart 10 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 10 • Toolbox 10.b.iii • Burns calculator Instructions A.Fluid deficit after burn 1.Calculate total burn area (Rule of Nines; Lund and Browder chart). Round to nearest 10%. 2.Estimate / measure the patient’s weight and round to nearest 10kg. 3.Read off the fluid deficit (in millilitres – white section) from time elapsed since burn (in hours – grey section). 4.Deduct the volume of any fluid already administered. 5.Replace deficit with Hartmann’s solution only. B. Maintenance fluid after burn 1.Read the hourly maintenance requirement (ml) from the purple section and replace as Hartmann’s solution. 2.Start this replacement at the same time the deficit is replaced. 3.Note that the hourly requirement changes after 8 hours from the burn. 10 4.Colloid is required after the first 8 hours following burn for children and after the first 24 hours for adults. 40 PER CENT BURNS Weight (kg) Fluid deficit Fluid maintenance Time post burn (hours) 8 10 20 30 40 50 60 70 80 90 100 940 1600 2100 2600 4000 4800 5600 6400 7200 8000 7 825 1400 1840 2275 3500 4200 4900 5600 6300 7000 6 710 1200 1575 1950 3000 3600 4200 4800 5400 6000 5 590 1000 1315 1625 2500 3000 3500 4000 4500 5000 4 470 800 1050 1300 2000 2400 2800 3200 3600 4000 3 355 600 790 975 1500 1800 2100 2400 2700 3000 2 235 400 525 650 1000 1200 1400 1600 1800 2000 1 120 200 265 325 500 600 700 800 900 1000 0–8 120 200 265 325 500 600 700 800 900 1000 ! ! ! ! 250 300 350 400 450 500 9–24 time elapsed from burn in hours fluid deficit in millilitres hourly maintenance requirement in millilitres Specialist burns advice essential TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 10.b.iii • Burns calculator 10 PER CENT BURNS Weight (kg) Fluid deficit Time post burn (hours) 8 20 30 40 590 1000 1315 1625 7 515 875 1150 1425 6 440 750 985 1220 5 370 625 820 1020 4 295 500 655 815 3 220 375 500 600 2 150 250 330 400 1 0–8 Fluid maintenance 10 9–24 75 125 165 200 75! 125 165 200 ! ! ! ! 10 50 60 70 80 90 100 ORAL FLUIDS ONLY 20 PER CENT BURNS Weight (kg) Fluid deficit Time post burn (hours) 8 20 30 40 50 60 70 80 90 100 705 1200 1575 1950 2000 2400 2800 3200 3600 4000 7 620 1050 1380 1710 1750 2100 2450 2800 3150 3500 6 530 900 1180 1460 1500 1800 2100 2400 2700 3000 5 440 750 985 1220 1250 1500 1750 2000 2250 2500 4 350 600 790 975 1000 1200 1400 1600 1800 2000 3 265 450 590 730 750 900 1050 1200 1350 1500 2 180 300 395 490 500 600 700 800 900 100 1 90 150 200 245 250 300 350 400 4450 500 0–8 Fluid maintenance 10 9–24 90 200 265 245 250 300 350 400 450 500 ! ! ! ! 125 150 175 200 225 250 30 PER CENT BURNS Weight (kg) Fluid deficit Fluid maintenance Time post burn (hours) 8 10 20 30 40 50 60 70 80 90 100 825 1400 1840 2275 3000 3600 4200 4800 5400 6000 7 720 1225 1575 2075 2625 3150 3275 4200 4725 5250 6 620 1050 1380 1780 2250 2700 3150 3600 4050 4500 5 515 875 1150 1420 1875 2250 2625 3000 3375 3750 4 410 700 920 1140 1500 1800 2100 2400 2700 3000 3 310 525 690 855 1125 1350 1575 1800 2025 2250 2 210 350 460 570 750 900 1050 1200 1350 1500 1 105 175 230 285 375 450 525 600 675 750 0–8 105 175 230 285 375 450 525 600 675 750 ! ! ! ! 190 225 260 300 340 375 9–24 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 10.b.iii • Burns calculator 40 PER CENT BURNS Weight (kg) Fluid deficit Time post burn (hours) 8 Fluid maintenance 10 20 30 40 50 60 70 80 90 100 940 1600 2100 2600 4000 4800 5600 6400 7200 8000 7 825 1400 1840 2275 3500 4200 4900 5600 6300 7000 6 710 1200 1575 1950 3000 3600 4200 4800 5400 6000 5 590 1000 1315 1625 2500 3000 3500 4000 4500 5000 4 470 800 1050 1300 2000 2400 2800 3200 3600 4000 3 355 600 790 975 1500 1800 2100 2400 2700 3000 2 235 400 525 650 1000 1200 1400 1600 1800 2000 1 120 200 265 325 500 600 700 800 900 1000 0–8 120 200 265 325 500 600 700 800 900 1000 ! ! ! ! 250 300 350 400 450 500 9–24 10 50 PER CENT BURNS Weight (kg) Fluid deficit Time post burn (hours) 8 20 30 40 50 60 70 80 90 100 1060 1800 2360 2925 5000 6000 7000 8000 9000 10000 7 925 1575 2065 2560 4375 5250 6125 7000 7875 8750 6 795 1350 1770 2195 3750 4500 5250 6000 6750 7500 5 660 1125 1475 1830 3125 3750 4375 5000 5625 6250 4 530 900 1180 1460 2500 3000 3500 4000 4500 5000 3 400 675 885 1100 1875 2250 2625 3000 3375 3750 2 265 450 590 730 1250 1500 1750 2000 2250 2500 1 130 225 295 365 625 750 875 1000 1125 1250 0–8 Fluid maintenance 10 9–24 130 225 295 365 625 750 875 1000 1125 1250 ! ! ! ! 315 375 440 500 565 625 60 PER CENT BURNS Weight (kg) Fluid deficit Fluid maintenance Time post burn (hours) 8 10 20 30 40 50 60 70 80 90 100 1175 2000 2625 3260 6000 7200 8400 9600 10800 12000 7 1030 1750 2300 2850 5250 6300 7350 8400 9450 10500 6 880 1500 1970 2445 4500 5400 6300 7200 8100 9000 5 735 1250 1640 2040 3750 4500 5250 6000 6750 7500 4 590 1000 1310 1630 3000 3600 4200 4800 5400 6000 3 440 750 985 1220 2250 2700 3150 3600 4050 4500 2 295 500 655 815 1500 1800 2100 2400 2700 3000 1 150 250 330 410 750 900 1050 1200 1350 1500 0–8 150 250 330 410 750 900 1050 1200 1350 1500 ! ! ! ! 375 450 525 600 675 750 9–24 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 10.b.iii • Burns calculator 70 PER CENT BURNS Weight (kg) Fluid deficit Time post burn (hours) 8 Fluid maintenance 10 20 30 40 50 60 70 80 90 100 1295 2200 2890 3575 7000 8400 9800 11200 12600 1400 7 1130 1925 2530 3180 6125 7350 8575 9800 11025 12250 6 970 1650 2170 2680 5250 6300 7350 8400 9450 10500 5 810 1375 1805 2235 4375 5250 6125 7000 7875 8750 4 650 1100 1445 1790 3500 4200 4900 5600 6300 7000 3 485 825 1085 1345 2625 3150 3675 4200 4725 5250 2 325 575 725 900 1750 2100 2450 2800 3150 3500 1 160 290 360 450 875 1050 1225 1400 1575 1750 0–8 160 290 360 450 875 1050 1225 1400 1575 1750 ! ! ! ! 440 525 615 700 790 875 9–24 10 80 PER CENT BURNS Weight (kg) Fluid deficit Time post burn (hours) 8 20 30 40 50 60 70 80 90 100 1410 2400 3160 3900 8000 9600 11200 12800 14400 16000 7 1235 2100 2765 3415 7000 8400 9800 11200 12600 14000 6 1060 1800 2370 2925 6000 7200 8400 9600 10800 12000 5 880 1500 1975 2440 5000 6000 7000 8000 9000 10000 4 705 1200 1580 1950 4000 4800 5600 6400 7200 8000 3 530 900 1185 1465 3000 3600 4200 4800 5400 6000 2 335 600 790 975 2000 2400 2800 3200 3600 4000 1 175 300 395 490 1000 1200 1400 1600 1800 2000 0–8 Fluid maintenance 10 9–24 175 300 395 490 1000 1200 1400 1600 1800 2000 ! ! ! ! 500 600 700 800 900 1000 90 PER CENT BURNS Weight (kg) Fluid deficit Fluid maintenance Time post burn (hours) 8 10 20 30 40 50 60 70 80 90 100 1530 2600 3415 4225 9000 10800 12600 14400 16200 18000 7 1340 2275 2990 3700 7875 9450 11025 12600 14175 15750 6 1150 1950 2490 3170 6750 8100 9450 10800 12150 13500 5 960 1625 2135 2640 5625 6750 7875 9000 10125 11250 4 765 1300 1710 2115 4500 5400 6300 7200 8100 9000 3 575 975 1280 1585 3375 4050 4725 5400 6075 6750 2 380 650 855 1055 2250 2700 3150 3600 4050 4500 1 190 325 430 530 1125 1350 1575 1800 2025 2250 0–8 190 325 430 530 1125 1350 1575 1800 2025 2250 ! ! ! ! 565 675 790 900 1015 1125 9–24 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 10.b.iii • Burns calculator 100 PER CENT BURNS Weight (kg) Fluid deficit Fluid maintenance Time post burn (hours) 8 10 20 30 40 50 60 70 80 90 100 1645 2800 3675 4550 10000 12000 1400 16000 18000 20000 7 1440 2450 3150 3985 8750 10500 12250 14000 15750 17500 6 1235 2100 2755 3415 7500 9000 10500 12000 13500 15000 5 1030 1750 2300 2845 6250 7500 8750 10000 11250 12500 4 825 1400 1840 2275 5000 6000 7000 8000 9000 10000 3 620 1050 1380 1710 3750 4500 5250 6000 6750 7500 2 410 700 920 1140 2500 3000 3500 4000 4500 5000 1 210 350 460 570 1250 1500 1750 2000 2250 2500 0–8 210 350 460 570 1250 1500 1750 2000 2250 2500 ! ! ! ! 625 750 875 1000 1125 1250 9–24 10 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 10 • Toolbox 10.c • Glasgow Coma Scale (GCS): adult Add the scores for the best response in each category to achieve the total score. Test Score Patient’s response Spontaneous 4 Opens eyes spontaneously To speech 3 Opens eyes to verbal command To pain 2 Opens eyes to painful stimulus None 1 Doesn’t open eyes in response to stimulus Obeys 6 Reacts to verbal command Localises 5 Attempts to remove source of pain Withdraws 4 Flexes and withdraws from painful stimulus Abnormal flexion 3 Flexes, but does not localise pain Abnormal extension 2 Extends limbs None 1 No response; just lies flaccid Oriented 5 Is oriented and converses Confused 4 Is disoriented and confused Inappropriate words 3 Replies randomly with incorrect words Incomprehensible 2 Incomprehensible sounds None 1 No response Eye opening Motor response 10 Verbal response Total score TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Adapted from: The Joint Royal Colleges Ambulance Service Liaison Committee (JRCALC) (October 2006) 10 • Toolbox 10.c • Glasgow Coma Scale (GCS): child Modification of Glasgow Coma Scale for children under 4 years old Test Score Eye opening As per adult scale Motor response As per adult scale Best verbal response 10 Appropriate words or social smiles, fixes on and follows objects 5 Cries, but is consolable 4 Persistently irritable 3 Restless, agitated 2 Silent 1 Total score TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Reproducible movement to command* Localisation to sound Auditory startle None 3 2 1 0 Objective localisation reaching* Visual pursuit* Fixation* Visual startle None 4 3 2 1 0 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Object manipulation* Localisation to noxious stimulation* Flexion withdrawal Abnormal posturing None/flaccid 4 3 2 1 0 Vocalisation / oral movement Oral reflection movement None 2 1 0 Non-functional: intentional* None 1 0 Attention Eye opening without stimulation Eye opening with stimulation Unarousable 3 2 1 0 Arousal scale Functional: accurate† 2 Communication scale Intelligible verbalisation* 3 Total score Automatic motor response* 5 Oromotor/verbal Function scale Functional object use† 6 Motor function scale Objective recognition* 5 Visual function scale Consistent movement to command* 4 Auditory function scale PatientDate: 10.d •JFK coma recovery scale (revised) 10 Date (start of symptoms) Time Symptoms experienced 10.e •Autonomic dysreflexia monitoring totol Stimulus identified 10 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Treatment given (end of symptoms) Time 10 • Toolbox 10.f • APC image transfer APC quick reference guide for Major Trauma Centre To access APC, navigate to https://apc.neeempacs.nhs.uk (this may be saved to your internet favourites) or click the APC icon on the Connect Portal homepage. If you receive a message concerning ActiveX controls, click ‘Allow ActiveX controls’. Support For in hours support, ask your system administrator ED: Karen Beesley karen.beesley@ addenbrookes.nhs.net Step 1: TU sends study A Trauma Unit makes contact with you regarding a major trauma case and notifies you that patient study / images have been sent via APC. Tel: 01223 216012 (ext 2012) Neuro: Sandra Taylor sandra.taylor@ addenbrookes.nhs.uk Step 2: Login Log into APC using your APC username and password and click Login If you’ve forgotten your details, click Forgot password. A new password will be sent to your e-mail address. Tel: 01223 3458433 (ext 58433) For out of hours support, contact the 24/7 Accenture service desk: PACS.Servicedesk@ accenture.com Tel: 0808 156 7227 * If you are having any password problems, you can contact your system administrator, see support details at bottom of page. Step 3: Find the study in the MDT group 1.To open a study that has been sent to the Addenbrookes-Trust MDT, click on the MDT button on the right hand side menu 2.Select the correct Addenbrookes_[Trust]_Major_Trauma MDT 3.This will show you all of the studies in this MDT Step 4: Starting an MDT Typically, a specialist from Addenbrooke’s will start the MDT. To do this: 1.Select the appropriate study from the list within the relevant MDT group 2.The received order information window opens 3.Click Start MDT meeting 4.Click Start MDT viewer to start the session and view the images TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network ATTENTION: All attendees must have the same screen resolution settings (or all use the settings of the user with the lowest resolution) 10 Step 5: Other users join the MDT Any number of specialists from the TU or MTC (providing they have APC accounts) can join the MDT to see a live stream of the images being discussed (Note: anyone in the meeting can take control of the image manipulation). They must: 1.Login > Find the study in the MDT group > Join the MDT (steps below) 2.Highlight the appropriate study from the list within the relevant MDT group 3.Click Join MDT meeting 4.You will now be able to view a live stream of the images being discussed – including annotations and manipulations in real time Use annotation tools to point to specific areas of the image rather than the mouse/cursor Step 6: End MDT 10 Once complete and a patient care decision has been reached: 1.The facilitator should click Start > Logout in the Image Viewer window 2.All attendees will be disconnected and can close the Image Viewer window (Note: If you are an attendee and wish to leave the MDT early, simply click Start > Disconnect me) Step 7: Decision point You now have a decision to make based on the situation. Select one of the following: Support For in hours support, ask your system administrator ED: Karen Beesley karen.beesley@ addenbrookes.nhs.net Tel: 01223 216012 (ext 2012) 1.No decision reached and a further MDT may be required… stop MDT but don’t complete it so it can be revisited 2.Patient to be treated at TU… complete the order sending any decisions reached back to TU sender 3.Patient to be transferred to MTC… import images into local PACS You will only need to do one of step 8a, 8b or 8c. Neuro: Sandra Taylor sandra.taylor@ addenbrookes.nhs.uk Tel: 01223 3458433 (ext 58433) For out of hours support, contact the 24/7 Accenture service desk: PACS.Servicedesk@ accenture.com Tel: 0808 156 7227 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Step 8a: Stop MDT but leave it ‘waiting’ If access to these images will still be needed through this MDT, then once you have ended the MDT: 1.From the consultation window, click Stop MDT meeting 2.The study will remain in the MDT orders waiting list, and another MDT can be started at any point (or the images viewed at any point) 1. F urther MDT discussion required Step 8b: Complete the order 10 If the patient is to be treated at the Trauma Unit, then complete the order to remove it from the MDT list (and send back any MDT discussion comments) 1.From the consultation window, add comments / notes into the Write answer text box 2.Click Send consultation 3.The comments will be returned to the sender, the study marked complete and removed from the MDT list Step 8c: Import images into PACS Complete the order (following step 8b) then follow existing processes to transfer / import images into local PACS if required. Step 9: Log out Don’t forget to log out. Once you are finished, click Logout in the top right corner. atient to be 2. P treated at TU 3. P atient to be transferred to MTC Support For in hours support, ask your system administrator ED: Karen Beesley karen.beesley@ addenbrookes.nhs.net Tel: 01223 216012 (ext 2012) Neuro: Sandra Taylor sandra.taylor@ addenbrookes.nhs.uk Tel: 01223 3458433 (ext 58433) For out of hours support, contact the 24/7 Accenture service desk: PACS.Servicedesk@ accenture.com Tel: 0808 156 7227 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 10 • Toolbox 10.f • APC image transfer APC quick reference guide for trauma units To access APC, navigate to https://apc.neeempacs.nhs.uk (this may be saved to your internet favourites) or double-click the APC icon on your desktop (if available). If you receive a message concerning ActiveX controls, click ‘Allow ActiveX controls’. Step 1: Login Log into APC using your APC username and password and click Login Support For in hours support, ask your system administrator (PACS manager) For out of hours support, contact the 24/7 Accenture service desk: PACS.Servicedesk@ accenture.com Tel: 0808 156 7227 If you’ve forgotten your details, click Forgot password. A new password will be sent to your e-mail address. 10 * If you are having any password problems, you can contact your system administrator, see support details at bottom of page. Step 2: Search for a patient study 1.To find a recent study, click New order on the menu on the right hand side 2.Enter the patient details in the ‘patient query’ window > click Search patient 3.Select the appropriate study from the list and click Continue Step 3: Send a study In the New order information screen: 1.Select MDT in the Type drop down menu 2.Select Emergency in the Specialties menu 3.Under Receivers click Add MDT > Search pools TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network If searching by name, be sure to insert a first and last name. Due to data protection, searches cannot be carried out with only a last name. 4.Select the appropriate MDT from the list (named Addenbrookes_[your Trust]_Major_ Trauma) > click OK 5.Select a Priority (this will be Urgent in most major trauma cases) > select a deadline and add any text to the order (you might want to add contact details of lead clinician) 6.Click Create new order You can use this Add attachment button to attach any pdf files/patient reports with the study. Step 4: View sent order status 10 Once you have sent your order, you will be taken to the My sent orders screen. You can navigate here at a later stage by clicking Sent orders Your order should be at the top of the list and will have one of the following status messages: Status: • Transferring: Image is in transit and cannot be viewed by the receiver • Waiting: Image has been transferred and is waiting in the receivers APC received orders • In progress: File has been opened by a receiver Step 5: MTC start MDT You then need to wait for the MTC specialist to start the MDT collaborative viewing feature. The MTC specialist will call to discuss the case and inform you that the MDT session has been started. You can then join the same meeting to share a collaborative view of the images being discussed. Step 6: Find the study in the MDT group 1.To open a study that has been sent to the Addenbrooke’s_Trust MDT, click on the MDT button on the right hand side menu 2.Select the correct Addenbrookes_Trust_Major_Trauma MDT Support For in hours support, ask your system administrator (PACS manager) For out of hours support, contact the 24/7 Accenture service desk: PACS.Servicedesk@ accenture.com 3.This will show you all of the studies/orders in this MDT Before joining you should try to select a PC that has the same resolution as all other attendees Tel: 0808 156 7227 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Step 7: Joining an MDT meeting Any number of specialists (providing they are set up as members of the MDT group) can join the MDT to see a live stream of the images being discussed 1.Highlight the appropriate study from the list within the relevant MDT group 2.Click Join MDT meeting 3.You will now be able to view a live stream of the images that are being discussed on the phone – including annotations and manipulations in real time. Note: Any participant has the ability to take control of the image/annotations and manipulations Step 8: Leaving an MDT meeting 10 To leave a live MDT meeting: 1.Click Start 2.Select Disconnect me Note: You must click Disconnect me to remove yourself from the meeting but allowing the meeting to continue. If you select Log out, it will end the MDT for all users Step 9: Reviewing Responses You can access the images you have sent for 28 days (including any comments). To view these: 1.Select sent orders > click on the Reading completed tab to see all of your completed orders (ie. those that have received responses) 2.Click on the relevant study to open consultation page to view the comments Step 10: Log out Don’t forget to log out. Once you are finished, click Logout in the top right corner. Support For in hours support, ask your system administrator (PACS manager) For out of hours support, contact the 24/7 Accenture service desk: PACS.Servicedesk@ accenture.com Tel: 0808 156 7227 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 11 Formulary 11 11 • Formulary 11.a • Tranexamic acid (TXA) Drug notes Inhibits fibrinolysis, therefore can be used to reduce bleeding Use Indications • Suspected bleeding in the context of major trauma (excluding isolated head injury) where the patient has either a heart rate >110 or systolic BP <90 Cautions Dose 1 – within 3hrs of incident Dose 2 – during 8hrs following incident • known allergy to Tranexamic acid • Adults: 1g IV at 60ml/hr over 8hrs 1g IV/IO over 10 mins • Children: 10mg/kg IV/IO over 10 mins (max 1g) Special groups • No evidence of harm in pregnancy Side effects • Nausea, vomiting • Hypotension on rapid injection Presentation Administration – dose 1 Administration – dose 2 500mg in 5ml, glass vial (100mg/ml) Required volume (dose) into 100ml 5% dextrose (in trauma bag) or 100ml N/Saline. Administer IV/IO over 5 –10 mins 1g tranexamic acid in 500ml of N/Saline over 8hrs at rate of 60ml/hr. Drug information Not a controlled drug Can be kept at room temperature Further information BNF: section 2.11 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 11 11 • Formulary 11.b • Co-amoxiclav Drug notes A combination of amoxicillin and clavulanic acid – broad spectrum antibiotic with aerobic and anaerobic activity Use Indications • To reduce infection associated with open fractures Cautions Dose • Should not be given to those with • Adults: a known PENICILLIN allergy 1.2g IV bolus • Children: 30mg/kg IV bolus (equivalent to 25mg/kg amoxil component) Special groups Side effects • Elderly normal dosing • Occasional GI upset or rash • Pregnant normal dosing • Rarely cholestatic jaundice Administration Reconstitute powder with normal saline (20ml) and administer IV (not suitable for IM) Drug information Not a controlled drug Store at room temperature Further information BNF: section 5.1.1.3 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 11 11 • Formulary Transfer infusions 11.d.i • Propofol 2% The MTC Outreach Service advocates the use of standard infusions for the transfer of patients to the MTC, detailed later (adapted from Magpas). Transfer service Drug notes Propofol 2% (20mg/ml) Hypnotic agent used for the maintenance of anaesthesia and sedation for ventilation or other procedures, 20mg per ml. Use Indications • As an infusion for maintenance of sedation and anaesthesia in ventilated patients Cautions Dose (1ml = 20mg) • Elderly • Adults: • Hypovolaemia • Children: 1– 4mg/kg/hr • Cardiovascular disease All predispose to hypotension and risk circulatory collapse 1– 4mg/kg/hr (0–20ml/hr) • Titrate to blood pressure • Adult bolus: 1–2mls Special groups Side effects • Safe in pregnancy • Hypotension (negatively inotropic and vasodilatory) • Safe in children for short term use • Apnoea Presentation: 50ml vial, white emulsion Administration Transfer Service uses only 2% solutions Only given as an infusion using an approved infusion pump. 1% solutions are available in hospitals Double-check strength prior to use Use only 2% Storage and stock No special storage requirements Drug information Not a controlled drug Can be kept at room temperature Further information BNF: section 15.1.1 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 11 11 • Formulary Transfer infusions 11.d.ii • Fentanyl infusion Transfer service Drug notes Fentanyl infusion Short acting opioid analgesic working at μ opioid receptors Use Indications • As an infusion for analgesia in ventilated patients only Cautions Dose • Frail / elderly (hypotension) • Adults: • Hypovolaemia (hypotension) • Children: 3mcg/kg/hr 3mcg/kg/hr (0–6ml/hr) • Hepatic or renal impairment (prolonged action) Special groups Side effects • Safe in pregnancy • Hypotension • Reduced dose recommended in elderly or debilitated patients • Apnoea Presentation: 10ml glass vials Administration 10ml glass vials Only given as an infusion (neat, no dilution) using an infusion pump. 50mcg per ml If no loading dose has been given, consider giving 1mcg/kg bolus followed by infusion. Onset of action: 5 minutes. Duration of action: 30 minutes Storage and stock Drug information A controlled drug Can be kept at room temperature Further information BNF: section 4.7.2 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 11 12 Policies 12 12 • Policies 12.a • Patient flow agreement Record of amendments Amendment No. Date Inserted by This agreement outlines the protocols and principles for the major trauma patient flow between the acute trusts in the East of England Integrated Trauma System. This major trauma patient flow agreement is between the East of England Trauma Network Office, acute trusts and commissioning bodies – named below. Major Trauma Centre Cambridge University Hospitals NHS Foundation Trust Trauma units Basildon and Thurrock University Hospital NHS Foundation Trust Bedford Hospital NHS Trust Colchester Hospital University NHS Foundation Trust East and North Hertfordshire NHS Trust (Lister Hospital) Ipswich Hospital NHS Trust James Paget University Hospital NHS Foundation Trust Luton and Dunstable Hospital NHS Foundation Trust Mid Essex Hospital Services NHS Trust Norfolk and Norwich University Hospital NHS Foundation Trust Papworth Hospital NHS Foundation Trust Peterborough and Stamford Hospitals NHS Foundation Trust Princess Alexandra Hospital NHS Trust Queen Elizabeth Hospital King’s Lynn NHS Trust Southend University Hospital NHS Foundation Trust West Suffolk NHS Foundation Trust Local emergency hospitals Hinchingbrooke Hospital Healthcare NHS Trust East and North Hertfordshire NHS Trust (Welwyn Garden City) Ambulance service East of England Ambulance Service Trust TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12 Commissioning Midlands and East Specialised Commissioning Group Norfolk and Waveney PCT Cluster NHS Suffolk North Essex PCT Cluster South Essex PCT Cluster Luton and Beds PCT Cluster NHS Hertfordshire Cambridgeshire and Peterborough PCT Cluster 12 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12 • Policies 12.a • Patient flow agreement Contents i. Introduction ii. Transfer of trauma patient from scene to Major Trauma Centre (MTC) or trauma unit (TU) – EoE major trauma triage tool iii. Secondary transfer of trauma patients from a trauma unit – call and send protocols iv. Reverse transfer of major trauma patients from a Major Trauma Centre back to a local trauma unit – call and receive protocol v. Summary of responsibilities to ensure effective patient flow vi. Financial penalties vii. Incident reporting 12 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12 • Policies Patient flow agreement 12.a.i • Introduction A recurrent finding in analysis of trauma care is that secondary emergency transfers from emergency departments or inpatient areas to Major Trauma Centres can take a long time to organise – from a personnel, equipment and transport platform perspective. Even when these aspects are addressed a further delay is often created by the need to: (a) formally refer the patient to an on-call team (b) Transfer images to the receiving hospital. The receiving hospital then has to communicate the acceptance of the transfer. The National Clinical Advisory Group recommended that: (a) Networks take the responsibility for the emergency transfer of patients between hospitals in the Network. (b) Network co-ordinators should be available 24/7 to manage the transfer of patients. (c) MTCs should be capable of accepting immediate transfers without warning. This agreement seeks to encourage a planned, co-ordinated and timely approach to the transfer and repatriation of all patients who have suffered traumatic injury across the east of England (EoE). All trauma patients in the EoE who trigger the trauma triage tool, will receive care either in the nearest Major Trauma Centre (MTC) or the nearest trauma unit (TU), and then transferred if necessary to the MTC or another trauma unit with specialist services. This agreement is divided into three parts and covers: Blue light transfer of trauma patients to a Major Trauma Centre or trauma unit, in accordance with the trauma triage tool, from the scene of the incident. Secondary transfer of major trauma patients from a trauma unit to the Major Trauma Centre. Reverse transfer of major trauma patients from a Major Trauma Centre back to a local trauma unit or rehabilitation provider. 12.a.ii • Transfer of trauma patient from scene to MTC or TU The trauma triage tool is used to determine: a)whether the patient meets the candidate major trauma patient criteria b)the appropriate hospital to transfer to: i. MTC: patient taken to the nearest MTC if within 45mins and possibly bypassing a local ED ii.TU: patient taken to the nearest TU if MTC is more than 45mins NB. In the event of exceptions to the trauma triage tool, MTC acceptance must be sought before transfer can take place. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12 Trauma triage tool Suspected major trauma? Does injured patient meet any of the criteria below? Physiology Sustained respiratory rate below 10 or above 29? (use JRCALC abnormal paediatric values for children) Sustained systolic BP below 90 mmHg or absent radial pulses? GCS motor score of 4 or less (withdrawal to pain or less)? Anatomy Open pneumothorax or flail chest? Suspected major pelvic fracture? More than one fractured proximal long bone? Crushed, degloved, mangled or amputated limb? Suspected open or depressed skull fracture? All pre-alerts and handovers should use the ATMISTER system: 12 Age Time Mechanism Injuries Signs Treatment ETA Requests YES NO Inform CCD now Channel 202 using ‘Priority RTS’ Inform CCD now Channel 202 using ‘Priority RTS’ and proceed to nearest emergency department Can Major Trauma Centre be reached within 45 minutes? YES Can airway, breathing and bleeding be controlled? NO Consider requesting pre-hospital medical team NO YES Go directly to nearest Major Trauma Centre Pre-alert MTC / ED Call 0300 330 3999 Select Option 1 NCS will put you through to the unit Go to nearest Trauma Unit TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12.a.iii • Secondary emergency transfer of trauma patients from a TU The emergency department (ED) communicates the need for secondary emergency transfer, according to the thresholds and clinical guidelines outlined in the Trauma East Manual for Procedures and Operations (TEMPO) and then calls to agree the transfer. The Network Co-ordination Service facilitates the clinical consultation between the referring ED trauma team leader, the duty MTC consultant, and where necessary a specialty champions/consultant. The ‘call and send’ should normally be an immediate transfer from the emergency department in the trauma unit (TU) after resuscitation. Where possible there should be no delay to the secondary emergency transfer of these patients. The call and send protocol authorises any emergency department within the network to commence the process of transferring a patient. Call and send protocol A: TU to MTC without waiting for the historical referral– acceptance process to be complete Call and send protocol B: TU to a TU with specialties services or a specialist centre 1.The following protocol should be used for call and send to the Major Trauma Centre: Major trauma patient arrives at trauma unit (TU) Patient treated by trauma team in accordance with ATLS/TEMPO guidelines Decision to transfer should be made within 1 hour Some patients taken to trauma unit on the basis of the Trauma Triage Tool will turn out to be less severely injured and will not need to be transferred to the Major Trauma Centre (MTC) YES Can the patient’s needs be met at the trama unit? Admit to trauma unit NO Trauma team leader to contact NCS and discuss transfer with MTC duty consultant Call and send – the responsibility for decision making will be with the senior consultant via the Network Co-ordination Service (NCS) Imaging should be transmitted immediately to the MTC (in line with TEMPO guidelines) Patient accepted by MTC YES Transfer to be arranged by NCS (unless TU providing transfer) Major trauma patient arrives at MTC TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network NO 12 2.The following protocol should be used for call and send to specialist services or a specialist centre Major trauma patient arrives at trauma unit (TU) Patient treated by trauma team in accordance with ATLS/TEMPO guidelines YES Admit to trauma unit Can the patient’s needs be met at the trauma unit? Decision to transfer should be made within 1 hour NCS will facilitate discussion between the trauma speciality champion and the MTC duty consultant – the responsibility for decision making will be with the MTC consultant 12 NO Do the patient’s injuries require a specialist hospital? Trauma team leader to contact NCS and discuss transfer with MTC duty consultant and trauma specialist consultant Has the patient been accepted for transfer to specialist hospital? NO Trauma leader to discuss case with MTC duty consultant YES Transfer to be arranged by NCS (unless TU providing transfer) Major trauma patient arrives at specialist hospital or specialist centre Network Co-ordination Service (NCS) – Tel: 0300 3303 999 The duty consultant at the Major Trauma Centre should be made aware of any major trauma patients taken to a trauma unit, via the Network Co-ordination Service. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 3.The NCS will facilitate clinical consultations at each phase. Clinical consultations regarding secondary emergency transfer will include the referring ED trauma team leader, MTC duty consultant and where necessary the trauma speciality champions/consultants. The specialty areas will include but are not limited to: • paediatric trauma • spinal cord injury (SCI) • vascular trauma •ortho-plastics • cardiothoracic trauma •burns • traumatic brain injury (TBI) • interventional radiology • traumatic amputations • complex orthopaedics 12.a.iv • Transfer of major trauma patients from a Major Trauma Centre back to a local trauma unit or rehab provider 1.In order to ensure the patient receives the right care in the right place appropriate to their needs and to manage patient flow, it is important to ensure that for patients whose specialist needs have been met, or can be met in a hospital closer to their home, that transfer out of the MTC takes place in an appropriate timeframe. Where a major trauma patient is to be discharged from a specialist centre the same will apply. This ‘call and receive’ protocol requires participating hospitals to accept patients who live in their catchment area from the Network whose needs can be met by that hospital. It is important to emphasise that this is not to allow the MTC to unblock beds – there has to be capability at the ‘call and receive’ hospital, not just capacity. 2.The agreement outlines the protocols and responsibilities for discharges from the Major Trauma Centre (MTC), as part of the Integrated Trauma System. This will: • ensure patients are treated at the right time, in the right place, and close to home where this is possible and appropriate • avoid delayed discharges within the MTC, which could then impact on service capacity and capability, and consequently on outcomes • align existing PbR and non-PbR funding with appropriate providers at each stage of the patient pathway 3.Within the MTC there will be an established rehabilitation team. This team will ensure that the patient’s pathway through the MTC and onwards into further stages of rehabilitation and reablement is completed in an efficient and timely fashion. The role of this team will be to: • identify the rehabilitation needs of the patient, plan for their discharge from the moment of their admission in liaison with relevant local trauma units or rehab providers, and • develop a prescription for rehabilitation for the patient following discharge from the MTC. TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12 4.It is not expected that this policy would apply to patients requiring critical care (level 3). Any such cases should be agreed between referring critical care units, and if necessary the trauma office can assist. The ‘call and receive’ protocol: Major trauma patient treated at the MTC Rehabilitation assessment undertaken by rehabilitation team and plan discharge from MTC to trauma units/rehab provider MTC estimated discharge date Rehabilitation team to notify NCS/EEAST with estimated transfer date NCS/EEAST start to prepare transfer Rehabilitation team to notify trauma unit/rehab provider 48 hours or 5 days (for complex patients) before, with estimated discharge date TU/rehab provider start to prepare to receive patient Rehabilitation team to confirm discharge date and time with TU/rehab provider and NCS/EEAST Transfer to happen within 1 day of the request from referring hospital MTC to receiving TU or rehab provider Patient transferred by NCS/EEAST Ensure rehabilition prescription bundle and necessary discharge paperwork is completed 12 Major trauma patient arrives at trauma unit or specialist centre TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12.a.v • Summary of responsibilities to ensure effective patient flow The Major Trauma Centre is responsible for: • immediately accepting primary and secondary transfers of all major trauma patients (where the ISS score is expected to be greater than 15), on the basis of immediate transfer, notification and clinical consultation • undertaking an immediate (where clinically possible) rehabilitation assessment and providing acute and rapid intervention rehab within the acute HRG spell • ensuring that each patient has a prescription for rehabilitation • on transfer, notifying the receiving hospital or other provider at least 48hrs prior to the transfer of the patient, or five days by mutual agreement where appropriate to the condition of the patient. More time may be necessary to manage the discharge of a patient with complex rehabilitation needs Hospital trusts are responsible for: • where trusts are designated as trauma units, meeting the trauma unit standards, particularly in relation to diagnostics and clinical co-ordination of secondary transfers • working with the MTC to support the delivery of the prescription for rehabilitation prior to the patient’s discharge from the MTC • receiving patients discharged from the Major Trauma Centre, with 48hrs notice or five days for complex patients (by mutual agreement) • taking back clinically appropriate patients where over-triage has resulted in admission to the MTC Commissioners (PCT and SCG) are responsible for: • ensuring that sufficient capacity is in place, and that capacity can be flexed as necessary, to provide the range of rehabilitation, ongoing care, home placement or palliative care packages which major trauma patients may need • ensuring, through contractual arrangements and individual packages of care, that patients can be received without delay, provided that 48hrs minimum notice has been provided • working with social care providers to ensure that social needs of patients are met enabling them to move into rehabilitation settings The Trauma Network Office (TNO) is responsible for: • system-wide co-ordination of rehabilitation (through a network rehabilitation co-ordinator) to support the commissioning and provision of rehab and ongoing care • alerting commissioners and providers where concerns are identified, or the system breaks down TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12 12.a.vi • Financial penalties Recognising the importance of optimising system wide capacity across the full patient pathway and improving clinical outcomes achieved through the more proactive provision of rehabilitation services, to minimise the risk of potential blockages to the required pathways, the following additional financial penalties will be applied if there is a breach to the patient pathway: Pathway 1 – primary transferred to the MTC There will be no financial penalty. Pathway 2 – secondary emergency transfers to the MTC The ‘Call and send protocol A’ (12.a.iii) should be followed it is a clear expectation that the MTC will accept EoE major trauma patients. In the event that the MTC does not accept these patients on a frequent basis then this will be discussed with the Trauma Network Office. If valid reasons are not supplied by the MTC a penalty will be introduced. NB. ‘Call and send protocol B’ (12.a.iii) relating to TU with specialist services or specialist centres, contract variations will be agreed further to the formal designation of trauma units in July 2012. Transfer from MTC to TU or rehab provider Where the MTC has provided the appropriate written notice and rehabilitation prescriptions of a patient’s suitability for discharge (unless such clinical suitability is disputed by the commissioner or receiving provider) and such discharge is prevented due to lack of available capacity or services, the MTC will be entitled to make an additional charge to commissioners of: a.£100 per bed day where the length of stay is within the relevant HRG trim point or; b. £100 per bed day where the length of stay is outside the relevant HRG trim point Within the spirit of the responsibilities set out above, the MTC will be responsible for the acute phase of the patient pathway covered by the terms of national guidance underpinning HRGs within the PbR guidance. This includes acknowledgement of the relevant trim points and the associated excess bed day tariff (currently £230 for all VA HRGs). 12 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12.a.vii • Incident reporting All Trusts within the EoE Trauma Network will continue to operate within their own clinical governance framework and all adverse incidents should be reported in line with their internal governance system. Any adverse incidents occurring during any part of the trauma patient’s pathway should be reported in line with the Trust’s internal process along with notifying the Trust’s Trauma Committee and the TNO Clinical Governance Manager. All operational partners, Trust’s and third sector health care providers are required to provide a summary of all of these adverse incidents / risks on a quarterly basis to the Trauma Network Office. Due to Trusts having their own reporting mechanisms the summary report to the TNO should only include the below information. These can be followed up further by the TNO if required. Date and time of incident Factual account of the incident Other parties involved Action taken or planned Outcome Supporting evidence if applicable These summaries should be sent to Clinical Governance Manager Trauma Network Office Lockton House Clarendon Road Cambridge CB2 8FH 01223 725355 Tel: Email: [email protected] 12 TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 13 Documentation 13 To open tear this edge first Patient stickers – left side if the patient is registered as UNKNOWN initially Affix postage stamp TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network The sticky strip can be used to attach registration details printed on a sheet in some departments etails of the D pre-alert should be written here. It follows the standard ATMISTER mnemonic used Clinical Governance East of England Major Trauma Network Lockton House Clarendon Road CAMBRIDGE CB2 8FH Back page East of England Trauma Network RR: 02 stats 22/05/2012 • Version: 1 • MRRG_00447 • MS112017 East of England Trauma Network Office • Tel: 01223 725355 Anaesthetics/ Intensive care General surgery Orthopaedics Emergency medicine HH:MM HH:MM HH:MM HH:MM HH:MM HH:MM HH:MM HH:MM H H : M M Details Y / N Y / N Y / N Y / N Y / N Y / N Y / N Y / N Arrival time Y / N Present for patient arrival? Y / N H H : M M people of all attending Y / N H H : M M the trauma call, Y / N H H : M M including time of CUH filing instructions: If patient admitted file within the relevant specialty divider under the clinical arrival, should be notes section of the casenotes. If not admitted file within the correspondence section of the casenotes. 1 Other Trusts: file in accordance with local policy. recorded here Grade Grade: Print name Grade: Nurse 2: Designation (please circle as appropriate) Major Trauma Team / ED Team Team leader & grade: Speciality GCS: mins Actual time of arrival: H H : M M Pulse: Nurse 1: Signature Print name / ED Consultant: Trauma team (print names below) Signature ETA % (air/ 02) BP: Request from pre-hospital team: eg. Blood / Specialist Treatment: Signs Injuries suspected: Good documentation always includes: • legible writing • times and dates If the pre- alert call is NOT from a service in the east of England, please call NCS Male / Female: Age: Time of incident: H H : M M If not East of England, call Network Co-ordination Service 0300 330 3999 Mechanism: Time: H H : M M Ambulance call sign: Call received by: Use hospital identification label Date: D D / M M / Y Y Y Y Pre-alert details Unknown patient sticker here For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Emergency Department Trauma Documentation Front page 13 • Documentation 13.a • Emergency department trauma documentation Completing the emergency department trauma documentation The East of England Trauma Network has designed a paper-based record that EDs can use to record care of their trauma patients. It is designed to record appropriate clinical information and Trusts will find that, if completed properly, it will be useful in the completion of TARN reports. 13 13 Yes / No 2 Designation: Colloid Call sign: mls Land mls Air mls Time: H H : M M Date: D D / M M / Y Y Y Y Blood Time of anaesthesia: H H : M M Transport from scene: Signature: Crystalloid Duration: H H : M M Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Incident location: Print name: Last eaten: PMH: Medications: Allergies: Notes: Pre-hospital fluids: Tranexamic acid: Yes / No Drugs and doses: Intubated: Pre-hospital interventions: Suspected injuries: Mechanism of injury: Patient trapped? Yes / No Incident No: Time of incident: H H : M M Pre-hospital information This page is designed to be completed by the pre-hospital team Yes / No Social history: Excess alcohol use: Tetanus status: Last meal: Pregnant: Other Events related to this injury Past medical history Medication (and description of any adverse events) Allergies Patient history Family history: Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 3 This reflects the ‘AMPLE’ history 13.a • Emergency department trauma documentation TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network E: /4 M: Collar Blocks /6 V: TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network mm Cap refill: Other: Intubated GCS: secs Circle the appropriate finding / 15 RL / ºC / LA Absent / LL Blood glucose: / mm Sluggish Yes / No Brisk Priaprism: Size: Left pupil: Reaction: / Absent mmol/l 4 Do you need immediate help? Escalate. If needed, call Network Co-ordination 0300 330 3999 Time: H H : M M Comments: Temperature: Sensory level: / Tender / min Scoop /5 SpO2: Free fluid: Hepato renal angle / Spleno-renal angle / Pericardium / Pelvis Sluggish RA / No apparent injury Brisk / Distended Size: / Pulse: Yes / No Nil / Free fluid Limb movement: Reaction: Right pupil: Disability / Obvious injury Soft Time: H H : M M Comments: FAST scan: Pelvis: Abdomen: External haemorrhage: BP: / Time: H H : M M Circulation mm Hg Left Right Comments: Flail chest Left Right Left Right Normal Spinal Board Compromised Reduced air entry Breathing (circle as appropriate) None Cervical spine immobilisation Patent Airway RR: / None / / L/min ETT H H : M M H H : M M Time CPR stopped: Yes / No Yes / No CSU sent Yes / No Yes / No H H : M M Antibiotics given ßhcG checked Initial rhythm: Yes / No Place sticker here Dose 2: Yes / No Circle the appropriate treatment 5 If a catheter is inserted, place the sticker from the catheter pack here H H : M M Time: H H : M M If yes at what time: Return of spontaneous circulation: Blocks Carried out by Other Yes / No HH:MM Left HH:MM HH:MM HH:MM Collar HH:MM Dose 1: Yes / No / Pre-hosp Antibiotics required (15min after catheterisation) Residual volume Size of catheter Time of catheterisation Urinary catheter Comments: Tranexamic acid given: Products arrived at: Left Other Carried out by: Surgical airway Carried out by / Yes / No Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ HH:MM Massive haemorrhage protocol activated: Yes / No Time of arrest: Right CPR performed: Splints: Site Site IV / IO access Circulation Thoracotomy (time 24hr) HH:MM / Chest drain (size and time 24hr) Nasal HH:MM Right Size: Oral Needle thoracocentesis Procedure Oxygen: Yes / No Breathing Time: H H : M M Adjunct Cervical spine immobilisation in Emergency Department: BP: Airway HR: Treatment Time: H H : M M Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ This page records the treatment of findings in the primary survey Initial observations Primary survey This page records the findings of the primary survey following the ABCD approach 13.a • Emergency department trauma documentation 13 13 6 C6 C7 C8 S1 L5 L4 L3 L2 L1 L5 L4 L3 L2 L1 T12 T11 T10 T9 T7 T8 T6 T1 T2 T3 T4 T5 C5 C3 C4 C2 S1 Location of injuries and interventions • I Secondary survey C6 C7 C6 C7 S1 S1 S1 S2 L5 S2 S2 L4 L3 L2 S4 S3 T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 C8 C7 C6 C5 C4 C3 C2 L5 S2 S2 S1 S1 Use hospital identification label S5 For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ C7 Left Dominant hand: left / right Location of injuries and interventions • II Secondary survey Right Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 7 13.a • Emergency department trauma documentation TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 8 Other: Neuro: Rectal: Spine: Lower limbs: Upper limbs: Pelvis / Perineum: Abdo: Chest: Neck: Face: Head: Body region findings Secondary survey List carefully all of the findings of the secondary survey Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Time: H H : M M MRI scan Yes / No Yes / No Date: D D / M M / Y Y Time: H H : M M Signed: 9 A full report will follow on PACS This A-D report should be completed by the radiologist at the time of scanning. It is an initial emergency report only that identifies major issues. Reporting Radiologist (print name): Other major injuries noted (please comment): Intracranial bleed Disability Soft tissue Pelvic Yes / No Small / Moderate / Large / No Abdominal If yes, please comment briefly: Right / Left / No Yes / No Thoracic Circulation (bleeding) Contusion/laceration Pneumothorax Right / Left / No Yes / No Breathing Satisfactory / Unsatisfactory ET placement (please circle) Head / CSp / CAP / Vascular Airway obstruction Airway CT performed (please circle) To guide initial management only. Formal detailed report will follow on PACS. Initial reports Time: H H : M M First FAST Time: H H : M M Head / Neck / Chest / Abdo / Pelvis / Legs / Other Time: H H : M M Yes / No CXR / PXR / C-spine Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Time: H H : M M Transfer of images to MTC (please circle) CT scan (please circle) Plain films Scans Radiology Record times of investigations and circle those performed 13.a • Emergency department trauma documentation 13 13 10 Contact/Bleep number: Time: H H : M M Designation: Date: D D / M M / Y Y Signature: I believe the preceding pages to be a true record of events. Print name: By signing here, the trauma team leader (TTL) is signing for the completion of all pages before this one. Designation: Signature: Print name: Nurse 2: This page does not need to repeat any details on the previous pages. It should be a record of any other information or interventions. Nurse 1: Nursing notes Most senior clinician present: Use hospital identification label Consultant: Team leader notes For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Contact/Bleep number: Time: H H : M M Date: D D / M M / Y Y 11 The specialty notes pages do not need to repeat any details on the previous pages. It should be a record of any other information, interventions or plans. Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 13.a • Emergency department trauma documentation TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12 Designation: Signature: Designation: Signature: Time: H H : M M Contact/Bleep number: Print name: Date: D D / M M / Y Y Most senior clinician present: Print name: Admitting Consultant: Orthopaedic notes Most senior clinician present: Use hospital identification label Admitting Consultant: General surgery notes For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Contact/Bleep number: Time: H H : M M Date: D D / M M / Y Y Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 13 13.a • Emergency department trauma documentation 13 13 14 Contact/Bleep number: Time: H H : M M Designation: Date: D D / M M / Y Y Signature: Designation: Signature: Print name: Most senior clinician present: Print name: Admitting Consultant: Anaesthetic notes Most senior clinician present: Use hospital identification label Admitting Consultant: Neurosurgery notes For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Contact/Bleep number: Time: H H : M M Date: D D / M M / Y Y Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 15 13.a • Emergency department trauma documentation TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 16 Designation: Signature: Designation: Signature: Time: H H : M M Contact/Bleep number: Print name: Date: D D / M M / Y Y Most senior clinician present: Print name: Admitting Consultant: Specialist notes Most senior clinician present: Use hospital identification label Admitting Consultant: Maxillo-facial notes For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Contact/Bleep number: Time: H H : M M Date: D D / M M / Y Y Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 17 13.a • Emergency department trauma documentation 13 13 18 Contact/Bleep number: Time: H H : M M Designation: Date: D D / M M / Y Y Signature: Use hospital identification label Print name: Most senior clinician present: Admitting Consultant: Specialist notes For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Time Lactate GLUC CREA UREA K Na pH INR PLTS WCC Hb Results HH : MM Results page HH : MM Affix blood gas here HH : MM HH : MM HH : MM Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 19 13.a • Emergency department trauma documentation TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Notes 20 Designation: Signature: Print name: Consultant: Destination: Outstanding tasks HH : MM HH : MM HH : MM HH : MM HH : MM HH : MM HH : MM HH : MM HH : MM HH : MM HH : MM HH : MM HH : MM HH : MM Time Team leader notes Chest: Abdomen: Circulation: Disability: Contact/Bleep number: Time: H H : M M Designation: Signature: Contact/Bleep number: Date: D D / M M / Y Y Print name: Comments: Limbs: Neurological: Back: 21 It may highlight injuries that were not immediately apparent during the resuscitation. The tertiary survey is usually completed within 24hrs of admission by one of the admitting team. Time: H H : M M Consultant: Other injuries: Neck: Breathing: Pelvis: Summary of injuries Head / face: Airway: Use hospital identification label Location Tertiary survey (once admitted) For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Date: D D / M M / Y Y The TTL should complete this as the patient is ready to leave the Completed ED. Details of any tasks outstanding should be written here. Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 13.a • Emergency department trauma documentation 13 13 Use hospital identification label 22 D D / M M / Y Y H H : M M If the MTC outreach service collect the patient, this section should be completed by the outreach service. Date: Signature: Comments: Time: Contact/Bleep number: Dr (print name): Handover to outreach service Designation: Time: H H : M M H H : M M Date: D D / M M / Y Y Time requested: All calls to NCS are recorded Signature: Yes / No H H : M M Conversations with the NCS consultant should be written here including any advice given. Time: Print name: Outreach service requested? NCS advice/plan: NCS Consultant: For inter-hospital transfers contact Network Co-ordination Service (NCS) on 0300 330 3999 For inpatient transfers follow Trust policy Patient transfer For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Ref: TARN input: not add other details to this section that might identify the patient further, eg. no patient stickers should be used. Date: D D / M M /Please Y Y Y Y do Received by: Trauma Network Office use only TARN ref number (if applicable) _ _ _ /_ _ _ /_ _ _ _ Tel: Hospital contact name: NHS number: Date: D D / M M / Y Y Y Y Private & confidential Fold & stick down securely Hospital number: Hospital: Patient details Detach from main document and complete details below It is important that the Trauma Network tracks all patients through the network. Completing this, folding and posting to the Network as soon as the patient leaves the ED is important. 13.a • Emergency department trauma documentation TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network Detach from main document along this perforation Signature TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 12 w e i Pev E L Name and designation Use hospital identification label File: under the Prescription Charts divider of the case notes (CUH) Name and designation Mr r A de S un Signature Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network Date and time Subsequent information gathered Date and time Initial information gathered (first 48 hours) Clinical assessment Trauma rehabilitation and transfer of care For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Back page Yes No (please specify) Orthopaedic Brain injury Vascular Amputation Burns E Liew Use hospital identification label For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ S un Consultant Futher plans (weight bearing etc, F/U) File: under the Prescription Charts divider of the case notes (CUH) Mr r A de Treatment / surgery (date) Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network Injuries Pev Abdominal Peripheral nerve Thoracic Spinal cord injury H H:M M East of England Trauma Network All entries must be dated, timed, name printed, signed with designation and contact/bleep number Neurological: Type(s) of injury sustained (tick as appropriate) Other people involved? GCS at the scene: Mechanism of injury: Date and time of occurrence: D D / M M / Y Y Y Y x Major trauma history Trauma rehabilitation prescription and transfer of care summary Specialist rehab prescription for major trauma patients (predicted ISS > 15) patients (version 6) Front page 1 13 • Documentation 13.b • Trauma rehabilitation prescription and transfer of care summary Please note: this document is undergoing review and is liable to change 13 13 2 w e E L Futher plans (weight bearing etc, F/U) Use hospital identification label File: under the Prescription Charts divider of the case notes (CUH) Mr r Pevi Consultant A de S un Treatment / surgery (date) Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network Injuries Clinical assessment Trauma rehabilitation and transfer of care For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Use hospital identification label A de Mr r Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network S un File: under the Prescription Charts divider of the case notes (CUH) E Liew Pev Home, family support, work, leisure, handedness, caring responsibilities, language, eligibility Life pre-injury (see e-discharge summary for detail) Investigations, past medical history, comorbidities, medication on admission and allergies Clinical assessment Trauma rehabilitation and transfer of care For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 3 13.b • Trauma rehabilitation prescription and transfer of care summary Please note: this document is undergoing review and is liable to change TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 4 Sedated Intubated b. 1 b. Commode c. Bottles b. 5–6 times c. > 6 times b. Once a. > 2 / day b. 2 / day c. Help of 1 and takes < 1/4hr d. Help of 1 > 1/4hr c. 1 / day c. Help of 1 and takes < 1/4hr d. Help of 1 > 1/4hr e. Help of 2 < 1/4hr f. Help of 2 > 1/4hr 48 hours 48 hours 48 hours Ward Ward Ward w e Discharge Discharge Discharge Discharge Discharge Discharge File: under the Prescription Charts divider of the case notes (CUH) c. Occasional faecal accidents (less than daily) d. Regular faecal accidents d. 4–5 times per week e. 2–3 times per week e. Help of 2 < 1/4hr f. Help of 2 > 1/4hr Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network a. Independent b. Set up only 5 Washing and grooming a. None b. Requires regular bowel regimen (suppositories/enemas) to prevent accidents 4.3 Faecal accidents d. More than twice c. 1–2 accidents/leakage in 24 hours d. > 2 accidents/leakage in 24 hours c. Twice 4.2 Frequency of opening bowels (or emptying colostomy bag) (eg. giving suppositories/enema) a. Independent b. Set-up only 4.1 Toileting: Bowels a. No accidents or leakage from catheter/convene b. Occasional accidents (less than daily) 3.4 Urinary accidents a. 0 times Toileting: Bladder – frequency of emptying bladder by night f. Pads d. Help at night only d. Help/supervision from 1 < 1/4hr e. Help from 1 > 1/4hr f. Help from 2 3.3 Toileting: Bladder – frequency of emptying bladder by day a. Empty bladder independently b. Set-up only (eg: copes if bottles left within reach) c. Indwelling catheter / convene a. Up to 4 times e. Bed-pan f. Pads Mr r d. Catheter/convene e. Bed-pan d. More than 2 A de S un b. Commode c. Bottles 3.2 Toileting: Bladder – need for assistance a. Toilet c. 2 d. Catheter/convene Toileting: Bladder – mode of emptying by night a. Toilet 3.1 Toileting: Bladder – mode of emptying by day a. 0 Ward Ward Ward E L Pevi d. Requires hoisting by 1 and takes < 1/2hr e. Requires hoisting by 2 and takes < 1/4hr f. Bed bound 48 hours 48 hours 48 hours Use hospital identification label d. Uses attendant-operated wheelchair e. Bed-bound (unable to sit in wheelchair) f. Walks with assistance/supervision of two 2.1 Frequency of bed transfers for rest periods during the day a. Fully independent b. Help from one person c. Help from two 2 Bed transfers a. Walks fully independently b. Independent in electric/self-propelled chair c. Walks with assistance/supervision of one 1 Mobility Section A • Basic care needs Disabilities: (Northwick Park Nursing Dependency Assessment) GCS total score Ventilated Assess the patient’s needs at each stage using the system indicated below Clinical assessment Trauma rehabilitation and transfer of care For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ b. 4–6 Mr r d. Intact, needs help from 2 to turn (4 hourly) e. Marked or broken, needs 1 to turn (2 hourly) f. Marked or broken, needs 2 to turn (2 hourly) Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network a. Compliant and socially appropriate b. Needs verbal/physical prompting for daily activities c. Needs persuasion to comply with rehab or care 12 Behaviour a. Communicate all needs b. Communicate basic needs with a little help or using aid ( < 1/4hr) c. Communicate basic needs with a little help or using aid ( > 1/4hr) 11 Communication 48 hours 48 hours 48 hours 48 hours File: under the Prescription Charts divider of the case notes (CUH) d. Needs structured behavioural modification programme e. Disruptive, inclined to aggression f. Inclined to wander off ward/out of house d. Respond to direct questions about basic needs e. Responds only to gestures and contextual clues f. No effective means of communication c. Requires help to maintain safety – a. Fully orientated, aware of personal safety could not be left for 2 hrs b. Requires some help with safety and orientation d. Requires at least hourly checks or constant but safe for 2 hrs supervision 10 Safety awareness a. Intact, able to relieve pressure independently b. Needs prompting only to relieve pressure c. Intact, needs help from 1 to turn (4 hourly) 9 Skin pressure relief a. None or indep b. Help to set up feed 1 / day c. Help to set up feed 2 / day Pev d. Help to set up feed 3 / day e. Extra flushes by day f. Extra flushes by day and night d. Drink independently but needs prompting to do so e. Help/supervision < 1/4 hr f. Help/supervision > 1/4 hr 48 hours Ward Ward Ward Ward Ward Ward Ward E Liew d. Intermittent check / supervision from 1 e. Help from 1 < 1/2 hr f. Help from 1 > 1/2 hr 48 hours 48 hours Use hospital identification label d. Drink independently but needs prompting to do so e. Help/supervision < 1/4 hr f. Help/supervision > 1/4 hr d. Help of 1 > 1/4hr e. Help of 2 < 1/4hr f. Help of 2 > 1/4hr A de S un c. 7 or more 8.3 Enteral feeding NG/PEG a. 3 Drinking – how many times in 24 hours? a. Entirely NG/PEG fed b. Pour own drink and drink it independently c. Drink independently if left within reach 8.2 Drinking a. NG/PEG fed b. Eats independently c. Drink independently if left within reach 8.1 Eating a. Entirely NG / PEG fed b. Pour own drink and drink it independently c. Drink independently if left within reach 7 Dressing a. Independent b. Set up only c. Help of 1 and takes < 1/4hr 6 Bathing – shower Section A • Basic care needs continued Clinical assessment Trauma rehabilitation and transfer of care Discharge Discharge Discharge Discharge Discharge Discharge Discharge For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 5 13.b • Trauma rehabilitation prescription and transfer of care summary Please note: this document is undergoing review and is liable to change 13 13 6 d. Maximal tracheostomy intervention c. Active tracheostomy intervention (eg. weaning, frequent suction) b. 2 No c. 3 or more 48 hours 48 hours 48 hours 48 hours 48 hours Ward Ward Ward Ward Ward Discharge Discharge Discharge Discharge Discharge Discharge Discharge Discharge File: under the Prescription Charts divider of the case notes (CUH) a. Daytime only b. Night time only c. 24 hours a day c. By nurse/skilled carer with rehab experience d. By either a specialty trained nurse (mentally unwell) or a qualified nurse (acutely unwell) c. 4 hourly monitoring of vital signs or specific intervention by qualified nurse < 2hrs / day d. Requires specific invervention by a qualified nurse > 2 hrs / day c. 1 person > 3 times in 24 hrs d. 2 people 1–3 times in 24 hrs e. 2 people > 3 times in 24 hrs Yes a. 1 c. Moderate (2 people) d. Complex (2 people, stretching required) c. Requires psychological support from more experienced nurse <2hrs / week d Requires additional time from an experienced nurse >2hrs / week Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network Time specialing required a. None b. Needs specialing (unskilled) 8 One to one specialing needs a. None b. Daily monitoring of vital signs 7 Intercurrent medical / surgical problem a. Able to maintain own posture b. Needs prompting or help from 1 person 1–3 times in 24 hrs 6 Postural management (in bed or chair) Night time splints? Frequency of splint application during the day a. No splints/able to apply own splints b. Simple splint application (1 person, no prior stretching) 5 Serial / resting splints a. No additional psychological support needed b. Requires frequent reassurance – can be provided by any care staff 4 Psychological support from nursing / care staff Number of times per day Supervised practise PEG meds IV meds CD meds If ‘d’ then what types of medication? Ward w e 48 hours Ward Ward E L c. Nurse dispenses and administers all medication d. Requires additional time from qualified staff c. Simple dressing (requires qualified staff intervention) d. Complex (requires qualified staff intervention or 2 people) 48 hours 48 hours Use hospital identification label Pevi Mr r A de S un a. No medication OR patient self medicates without supervision b. Supervised practise – patient dispenses and takes medication under supervision 3 Medication a. No wound dressing/self-management b. Simple dressing (does not require qualified staff) 2 Wound dressing or problematic stoma dressings a. No tracheostomy in situ/or self management b. Maintenance tracheostomy intervention (eg. changing inner tube, minimal suction < 2 day) 1 Tracheostomy management Section B • In-patient nursing needs Clinical assessment Trauma rehabilitation and transfer of care For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ b. Family c. Home care d. Nurse b. Family c. Home care b. family c. home care d. nurse e. other / unknown c. home care No Yes Presence of psychosocial factors affecting activities or participation Not assessed Not assessed Not assessed Not required 48 hours 48 hours 48 hours File: under the Prescription Charts divider of the case notes (CUH) No Yes Presence of cognitive/mood factors affecting activities or participation Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network No No Yes Yes No No No No Presence of physical factors affecting activities or participation Rehabilitation prescription (completed or not required Yes Yes Yes Yes e. other / unknown (this section MUST be completed before discharge) The TARN minimum dataset Police or solicitor contact information Power of attorney or court of protection in place? Mental capacity or deprivation of liberty issues? Safeguarding factors? Laundry Shopping Heavy housework Light housework d. nurse A de S un b. family 5 Do they require help for domestic duties? a. No help needed Skilled help needed for special medication? (eg. insulin injections) a. No help needed e. Other / unknown Mr r d. Nurse Skilled help needed for pressure sore / wound dressing? a. No help needed Pev e. Other / unknown Skilled help needed for stoma care? (eg. tracheostomy, gastrostomy) a. No help needed 48 hours Ward Ward Ward Ward Ward E Liew c. Able to help themselves if tablets left out in the morning d. Requires help for medication to be given c. Able to help themselves if a snack is left out in the kitchen d. Needs meals or drinks putting in front of them d. No – does not have stairs at home 48 hours Use hospital identification label c. No – unable to do stairs (stays on one level) Skilled help needed for suppositories / enema? 4 Skilled help a. N/A (eg. on none) b. Independent 3 Medication a. Not applicable as entirely gastrostomy fed b. Able to make a snack and drink at home independently 2 Making a snack / meal a. Yes – without help b. Yes – with assistance/supervision 1 Is patient able to go up/down stairs at home? Section C • Care needs assessment Clinical assessment Trauma rehabilitation and transfer of care Discharge Discharge Discharge Discharge Discharge For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 7 13.b • Trauma rehabilitation prescription and transfer of care summary Please note: this document is undergoing review and is liable to change TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 8 Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network File: under the Prescription Charts divider of the case notes (CUH) E L Pevi Mr r A de S un Pain management, therapists involved etc w e Use hospital identification label Rehab plans, goals and progress (or attach own discharge summary) Clinical assessment Trauma rehabilitation and transfer of care For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network File: under the Prescription Charts divider of the case notes (CUH) Contact/Bleep number: Time: H H : M M Signature: Designation: Date: D D / M M / Y Y Y Y Print name: Date of prescription: D D / M M / Y Y Y Y Discharge destination: Level 1 – highly specialist rehab (rehab consultant led) Level 2 – local specialist rehab (led or supported by rehab consultant) Level 3a – other local specialist service (led by consultant in other speciality) Level 3b – local non specialist services (not consultant led) Other key issues (eg. potential barriers to discharge) E Liew Contact details Use hospital identification label Pev Mr r Date A de S un Level of service required on discharge Discuss with rehab medicine if needs level 1 or 2 Discharge Profession Clinical assessment Trauma rehabilitation and transfer of care For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 9 13.b • Trauma rehabilitation prescription and transfer of care summary Please note: this document is undergoing review and is liable to change 13 13 Use hospital identification label Splinting/orthotics Seating/wheelchair Physical therapy: active/passive handling Respiratory/Tracheostomy management Swallowing Nutrition Supported communication Speech and language interventions 2 3 4 5 6 7 8 9 Domestic/community based activities Vocational/leisure/computers/driving Cognitive interventions Behavioural management Emotional/Mood Formal family support Emotional load on staff Planning discharge/housing/care package Benefits and finances Equipment/adaptation for home Community/home visits Keyworking 11 12 13 14 15 16 17 18 19 20 21 22 Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network Personal/self-care 10 10 E L File: under the Prescription Charts divider of the case notes (CUH) w Pevie Mr r A de S un Medical management 1 Rehab medicine consultant to complete if appropriate, eg. ISS>15 Clinical assessment Trauma rehabilitation and transfer of care For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ High (+ assistant) Very high >30 hours/week Specialist 6 Pev Acute medical / surgical Potentially unstable 4–5 48 hours Ward E Liew High dependency Very high 1:1 supervision 4 Use hospital identification label Specialist nursing High 3 carers 3 File: under the Prescription Charts divider of the case notes (CUH) Total score: Mr r Moderate (eg. daily) 2–3 Specialist Rehab nurse Medium 2 carers 2 A de S un Basic Low level (less than daily) 1 Basic Qualified nurse Low 1 carer 1 Date: 08/10/2012 • Trauma rehab prescription • Version: 1 • MRRG_00000 • MS120302c © East of England Trauma Network Notes None None Therapy intensity Equipment None None active None None Independent 0 Therapy disciplines Medical Nursing Risk Care RCS-E Summary Clinical assessment Trauma rehabilitation and transfer of care 11 Discharge For staff use only: Hospital number: Surname: First names: Date of birth: NHS no: _ _ _ / _ _ _ / _ _ _ _ 13.b • Trauma rehabilitation prescription and transfer of care summary Please note: this document is undergoing review and is liable to change TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 14 Audit and feedback 14 14 • Audit and feedback 14.b • Red card feedback TEMPO guidance is developed by clinicians using the best evidence available and their collective experience. It benefits from regular review (at least yearly) and occasional changes of important topics as new evidence becomes available. Those using the guidance in practice are encouraged to provide feedback on • any errors • new evidence on a topic • a topic that you feel should be covered but currently isn’t • a topic that you feel should be covered in a better way Trauma Committees are the focus within acute trusts for trauma care and it is useful to discuss any changes with them before proposing to the Network. Photocopy and complete the form below and post to the Trauma Network Office, or use the electronic form on our website www.eoetraumanetwork.nhs.uk Name Email Role Organisation Page number (if relevant) Feedback TEMPO Guidelines • v1 • Nov 2012 • NHS East of England Trauma Network 14
