Textbook of Acute Trauma Care

Foreword
Acknowledgements
Contents
Contributors
Part I: Trauma Systems and Teams
1: Human Factors in Trauma Care
Introduction
What Are Human Factors and Why Should We Care?
Causes of Error
General Principles
Flow Disruptions
Active and Latent Failures
Individual Factors
Stress and Adverse Physiologic States
Managing Stress and Increasing Cognitive Readiness
Cognitive Bias
Task Factors
Checklists
Team Factors
Don’t Just Debrief, Prebrief
Team Structure: Leadership and Followership
Shared Mental Models
Communication
Handovers and Debriefs
Environmental Factors
The Zero Point Survey
Physical Layout
Resource Utilization
Organizational and System Factors
Safety-I and Safety-II
References
2: Dealing with Death in Trauma
Introduction
Death Trajectories
The Bad Death
Dealing with Death: The Family
Dealing with Death: The Clinical Team
Dealing with Death: The Expert
References
3: Legal and Ethical Issues in Trauma Care
Introduction
Principles and Opinion
Principles and Opinion
Principles and Opinion
Principles and Opinion
Reporting Domestic Violence
Principles and Opinion
Principles and Opinion
Principles and Opinion
Principles and Opinion
Appendix: Post Mortem Narrative Tool
References
4: The Evolution of Trauma Systems
Introduction
How Did We Get to our Current System and Does it Work?
What Challenges Remain?
References
Part II: The Fundamental Approach to Trauma Patients
5: Point of Injury to Rehabilitation
Introduction
When to Start the Assessment?
The Reprioritisation of Haemorrhage Control
A Universal Treatment Algorithm
Overarching Principles of MABCD
Massive External Haemorrhage
Airway
Breathing
Circulation
Disability and Head Injuries
Exposure
Onward Care
References
6: Massive Haemorrhage Control
Introduction
What Is Massive Haemorrhage?
Sources of Massive Haemorrhage
External Bleeding
Skin/Scalp Bleeding
Facial Trauma
Pelvic Trauma
Treatment of Massive Haemorrhage
Compressible Haemorrhage
Indirect Pressure
Tourniquets
Haemostatic Dressings
Junctional Haemorrhage
Non-compressible Haemorrhage: Torso
Fluid Management
References
7: Fundamentals of Airway Management in Trauma
Introduction
The Case Against Intubation
Why Manage the Airway?
Airway Management Philosophy
Team Composition
Initial Airway Management and Causes of Airway Compromise
Diagnosing Airway Obstruction
Positioning, Basic Manoeuvres and C-Spine Injuries
Basic Airway Adjuncts
Supraglottic Airway Devices
Surgical Airways/Emergency Front of Neck Access (eFONA)
Cannula and Seldinger Techniques
Surgical Techniques
Conclusion
References
8: Drug Assisted Airway Management
Introduction
Airway Anatomy
Rapid Sequence Induction of Anaesthesia and Intubation
Cricoid Pressure
Choice of Induction Agents for Rapid Sequence Induction
Thiopentone
Ketamine
Propofol
Etomidate
Choice of Paralytic Agent
Rocuronium
Suxamethonium
Protocolising Interventions
Difficult Airways
Predicting a Difficult Airway
Specific Anatomical Difficulties
Situationally Difficult Airways
Video Laryngoscopy
Failed Intubation and Surgical Airways
Sedation and Anaesthesia for Transfer
Conclusion
References
9: Breathing and Chest Trauma
Introduction
Applied Anatomy and Common Pitfalls
Physiology of Normal Breathing
Oxygenation
Ventilation and V/Q Matching
Respiratory Failure
Assessment of Chest Injuries
Diagnoses of Immediately Life-Threatening Chest Trauma
A: Airway Obstruction
T: Tension Pneumothorax
O: Open Pneumothorax
M: Massive Haemothorax
F: Flail Segment
C: Cardiac Tamponade
Other Serious Pathology: The Sub-acute Six
G: Great Vessel Injury
Aortic Injuries
Vena Cava Injuries
O: Oesophageal Injury
T: Tracheobronchial Injury
C: Cardiac Contusion
P: Pulmonary Contusion
D: Diaphragmatic Rupture
Escalation of Respiratory Support from Basics to Advanced Critical Care
Basic Principles and Baseline Care
Intermediate Options
Advanced Interventions Available Commonly
Super-Specialised Centre Options
Practical Procedures: Thoracostomies and Insertion of Chest Drains
Insertion Technique
Conclusion
References
10: Circulation
Introduction
Gross Physiology of Circulation and Blood Pressure
Shock
Distributive Shock
Anaphylaxis
Sepsis
Neurogenic Shock
Obstructive Shock
Pulmonary Embolus
Tension Pneumothorax
Cardiogenic Shock
Cardiac Tamponade
Hypovolaemic Shock
Failure to Identify Active Bleeding
Failure to Control Active Bleeding
“Classical” Clinical Signs of Shock
Metabolic Assessment of Shock
pH and Base Excess/Deficit
Lactate
Haemoglobin
Other Biomarkers
Hypotension in Trauma
History of Permissive Hypotension
Permissive Hypotension as a Concept
Cyclic Hyper-resuscitation and Crystalloids
Fluid Therapy in Trauma
Colloids
Synthetic Oxygen Carriers
Blood Transfusions in Trauma
Oxygen Content of Blood
Cardiac Output, Blood Pressure and Flow
Blood Components or Warm Fresh Whole Blood?
Practical Aspects of Blood Transfusion
Active Management of Circulatory Failure
In-Hospital On-Going Care
Brain Injury and Permissive Hypotension
Damage Control Resuscitation
Failure to Respond to Resuscitation
Summary
References
11: Disability and Head Injury
Introduction
Primary Versus Secondary Brain Injury
Applied Anatomy
Physiology
Assessment of Head Injuries
Level of Consciousness
Problems with GCS
Pupils
Focal Neurological Deficit
Treatment and Principles of Care
Initial Treatment
Continued Management
CT Scanning
Neurosurgical Consultation
Diagnosis and Management of Specific Pathologies
Skull Fractures
Focal Brain Injuries
Contusions
Extradural Haematomas
Acute Subdural Haematomas
Diffuse Brain Injuries
Neuro Intensive Care
Summary
References
12: Traumatic Cardiac Arrest
Introduction
Epidemiology
Presentation
Management
Cardiopulmonary Resuscitation
Reversing the Reversible
Hypovolaemia
Oxygenation
Airway Management
Ventilation
Traumatic Asphyxia
Impact Brain Apnoea
Spinal Injury
Tension Pneumothorax
Tamponade
Resuscitative Thoracotomy in Traumatic Cardiac Arrest
Risk to Clinicians
Patient Selection
Surgical Technique
Clamshell vs Anterolateral Approach
Clamshell Thoracotomy
Other Manoeuvres
Medical Confounders
Human Factors in Traumatic Cardiac Arrest
Other Causes of Arrest Relevant to Trauma
Commotio Cordis
Lightning
Electrocution
Hypothermia
Hanging/Strangulation
Forensic Aspects
Conclusion
References
13: Pain Management in Trauma
Assessing Pain
Non-Pharmacological Treatments
Splinting
Reduction
Irrigating
Covering
Routes of Drug Administration
Intravenous (IV)
Interosseous (IO)
Intramuscular (IM)
Intranasal (IN)
Subcutaneous (SC)
Transdermal
Oral
Oral Transmucosal
Inhalational
Brief Pharmacological Comparison of Analgesics
Opiates (Oral, IV, IM, IO, Transmucosal, Intranasal)
Paracetamol/Acetaminophen (Oral, IV, Rectal)
NSAIDs (Oral, IV, IM)
Ketamine and S-Ketamine
Neuropathic Pain Modulating Agents
Gabapentin/Pregabalin
Amitriptyline
Regional Anaesthesia
Compartment Syndrome
Specific Regional Anaesthetic Techniques
Upper Limb Blocks
Brachial Plexus Anatomy
Interscalene Block
Supraclavicular Block
Infraclavicular Block
Axillary Block
Lower Limb Blocks
Lumbar and Sacral Plexus Anatomy
Femoral Block
Saphenous Block
Sciatic Block
Analgesia for Thoracic Trauma
Regional Techniques for Thoracic Trauma
Intercostal Block
Intra/Inter-Pleural Block
Paravertebral Block
Thoracic Epidural (+/− Opioid)
Serratus Anterior Plane Block
Local Anaesthetic Systemic Toxicity
The Algorithm for Management of LAST Includes
Analgesia for Neuro-Trauma
Clinical Pearls in the Management of Acute Pain in a Patient Following Trauma
Initiating Patient Controlled Analgesia in the Acute Setting for Pain Management
Chronic Pain After Trauma
Summary
References
Further Reading
Regional Anaesthesia
IO Access
Intransal Drug Administration
Part III: Haemostatic Interventions in Trauma
14: Initial Approach to Damage Control Resuscitation
What Is Damage Control?
Philosophy of Damage Control Resuscitation
History and Concepts Around Damage Control Surgery
Damage Control Anaesthesia
When to Start Damage Control Resuscitation: Indications
Damage Control Resuscitation in PHEM
Damage Control Resuscitation in ED
Damage Control: More Than Surgery
References
15: Haemostasis and Coagulopathy
Introduction
The “Classical” Clotting Cascade
Trauma Induced Coagulopathy
TIC: Pathophysiology and Mechanism
The Theory of DIC-Fibrinolysis
The Theory of Activated Protein C
The theory of Glycocalyx injury
The Theory of Hypofibrinogenaemia
The Role of Platelets
Haemostasis and Resuscitation
Tranexamic Acid
Historical Evolutions
Conclusion
References
16: In Hospital REBOA for Major Trauma
Introduction
Assumptions
Purpose of REBOA
Probable Haemodynamic Effect of REBOA in Humans
Use of REBOA Within a MTC
Definition
Indications/Contraindications
Types of REBOA
Level of Balloon Deployment
Strategy of Occlusion
Duration of Balloon Inflation
Consider with Level and Strategy of Occlusion
Environment of insertion
Access Type
Access Location
Type of Balloon Catheter
Risk Analysis for REBOA
Escalation of Readiness for REBOA
Rationale to Gain Femoral Access with REBOA Decision Not Yet Made
Specific Injuries Affecting Access Considerations
Risk Analysis for Conduct of REBOA
Identifying the Highest Impact Group
Identifying Level of Bleeding
Ensuring an Immediate Exit Strategy
Practical Considerations in the Conduct of REBOA
Equipment Readiness
Technique of REBOA Catheter Use
Sheath Access (in this Example: CFA and Percutaneous)
Balloon Catheter Insertion
Adjusting Level of Aortic Balloon Occlusion
In Conjunction with Definitive Haemorrhage Control
Balloon Deflation and Removal of Catheter
Sheath Management Plan
Lower Limb Fasciotomies
Current Literature Perspective
Comparison to Resuscitative Thoracotomy
Extrapolating Epidemiological Data Is Problematic
REBOA Human Evidence Base
Future Availability of OCEBM Level 2 Evidence
System Optimisation for REBOA
Access to a Suitable Training Programme
Audit and Clinical Governance
REBOA Protocol or Guidance
Conclusion
References
17: Anticoagulants in Trauma
Introduction
Anticoagulants: Types and Assessing Anticoagulant Effect
Vitamin K Antagonists (VKA) Also Called Coumarins: Warfarin (Coumadin), Dicumarol (Dicoumarol), Acenocoumarol (Sinthrome), Phenindione
Direct Oral Anticoagulants (DOACs: Formerly Called NOACs (Novel Oral Anti Coagulants))
Direct Thrombin Inhibitors: Dabigatran (Pradaxa)
Factor Xa Inhibitors: Apixaban (Eliquis), Edoxaban (Lixiana) and Rivaroxaban (Xarelto)
Low Molecular Weight Heparin (LMWH), Heparin (Unfractionated Heparin, UFH) and Fondaparinux
Antidotes for Anticoagulants
For Warfarin
Vitamin K
4 Factor Prothrombin Complex Concentrate (PCC). Beriplex or Octaplex
For Dabigatran
Idarucizumab (Praxbind, Boehringer Ingelheim)
For Direct Factor Xa Inhibitors: (Apixaban, Edoxaban and Rivaroxaban)
Andexanet Alfa (Ondexxya or Andexxa Manufactured by Alexion)
4 Factor Prothrombin Complex Concentrate & DOAC Reversal
For Unfractionated Heparin (UFH)/Heparin
Protamine
Toxbase Guidance
British Society for Haematology Guidance (BSH)
For Low Molecular Weight Heparin (LMWH)
Protamine
Protamine Reversal for LMWH: Courtesy of Toxbase
Andexanet Alfa
For Fondaparinux
Anti-Platelet Agents
Summary
References
Part IV: Pre-hospital Aspects of Trauma Care
18: History of Pre-Hospital Medicine in the UK
Antiquity to Early Modern
Late Modern: 1860–1945
Contemporary: 1945—Present
Conclusion
References
19: Aviation Considerations in PHEM
HEMS vs Air Ambulance
Aviation Legalities
Permissions and Exemptions
Minimum Heights SERA3105
Prisons
Nuclear Facilities
Landing and Taking off Near Open-Air Assemblies
Pilot Duty Period and Discretion
Carriage of Patients
Carriage of Escorts
Call Taking and Tasking
Radio Procedures
Comms Panel in the Aircraft
Maps and Charts
The UK Grid Reference System
A-Z Maps or Street Mapping
In-Flight Navigation
Lookout and the Clock Code
Weather Limitations
Disc Safety
Main Rotor
Tail Rotor
Disc Discipline
Disc Protection on Landing and Take off
Takeoff and Landing Checks
Landing Site Selection
Landing Site Recce: Arrival and Approach
Wheels and Stinger Check
Specific Landing Site Considerations
Railways
Reservoirs
Beaches
Prisons
Industrial Incidents
Airport Landings
IFR Recoveries
Night Flying
Procedures for Departure from a HEMS Site at Night
Marshalling Signals
Aircraft Emergency Procedures
Batteries
Conclusions
References
20: Scene Safety
Introduction
Environment
Temperature and Weather
Traffic
Kit Management
Being Prepared and Escalating Concerns
Personal Protective Equipment (PPE)
Training SOP’s and Sign Off
Beginning of Shift Checks and Procedures
Driving
Multiagency Working
Dynamic Risk Assessment
Manual Handling
Infection Control
Police and Evidence
Fire and Rescue Services
Communication
Verbal and Non-Verbal Communication
Team Debriefing
Conclusion
References
21: Mechanism of Injury
Introduction
Understanding the Physical Forces Involved
Grouping of Injury Types
Blunt Trauma
Penetrating Trauma
Ballistic Trauma
Acceleration and Deceleration Trauma
Road Traffic Collisions
Frontal/Head-on
Rear Impacts
Side on/“T-Bone” Collision
Rollover
Pedestrian
Cyclists and Motorcyclists
Falls
Equestrian Accidents
Kicks
Falls from a Horse
Summary
References
22: Mass Casualty Incidents
Introduction
Types and Scope of Major Incidents
CBRNE3T
Preparation
Organisational Preparedness
Individual Preparedness
Public Involvement
CSCATTT
Command, Control and Coordination of an Incident
Primacy at Scene
Safety
Communication
Assessment
Triage
MPTT-24: A New Triage Tool
Treatment
Transport
Crew Resource Management & Human Factors
Debrief
Summary
References
23: Tactical Trauma Care
Introduction
War Wounds on Home Soil
Phases of Care
Care Under Fire/Non-Permissive Environment
Tactical Field Care/Semi-Permissive Environment
Resuscitation and Advanced Care/Permissive Environment
The Physiology and Anatomy of Tactical Trauma Care
Physiology
Anatomy and Wounding
Unique Challenges of Tactical Trauma Care
CBRNE3T
The MABCD Approach in the Tactical Environment
Care Under Fire
Tactical Field Care
Challenges of International and Austere Working
Conclusion
References
24: Trauma Retrieval
Introduction
Training
Key Points in Transfer Medicine
Trauma Retrievals
Human Factors
Situational Awareness
Team Structure and Function
Standardisation and Processes
Checklists and Establishing the Appropriate Norms
Simulation Training
Command and Control
Preparation
Loading Plan
Equipment Packaging and Carriage
Feeling Included
Communication within the Team
Mission Communication
Clinical Information
Team Welfare
Infection Control
Recovery Phase
Contemporary Transfer Medicine
Conclusion
References
25: Sedation and Field Amputation
Introduction
Sedation
Sedation in Practice
Sedation for Painful Procedures
Sedation for Amputation
Indications for Pre-Hospital Amputation
Equipment for Pre-Hospital Amputation
Main Risks of the Procedure
Pre-Procedure Checks
Immediately Before the Procedure
The Surgical Procedure
Immediate Actions Post Procedure
Delayed Actions After Procedure
Novel Techniques for Surgical Amputation
Training for the Procedure
Overview of Drugs Commonly Used in Procedural Sedation
Midazolam
Ketamine
Propofol
Methoxyflurane
Morphine
Fentanyl
Alfentanil
Entonox
Conclusion
References
Part V: Radiology in Trauma
26: Point of Care Ultrasound (POCUS)
Introduction
Physics
Ultrasound
Waveform
Mechanics
Resolution
Artefacts
Doppler
Hardware
Probes
Image Optimisation
Modes
Probe Handling
Video Resources
Systems
Airway
Breathing
Pneumothorax
Intra-Alveolar Fluid
Circulation
Cardiac
Abdominal
Vascular Access
Disability
Exposure
Cardiac Arrest
Limitations & Governance
Conclusion
References
Recommended Further Reading
27: Diagnostic Radiology in Trauma
Introduction
Trauma Imaging Modalities
Digital Radiography
Ultrasonography
Computed Tomography
Magnetic Resonance Imaging
Fluoroscopy
Catheter Angiography
Injury Patterns in Major Trauma
Head and Neurological Trauma Imaging
Chest Trauma Imaging
Abdominal and Pelvic Trauma Imaging
Special Considerations
Children
Pregnancy
Elderly
Adverse Events Associated with Administration of Intravenous Contrast
Conclusion
References
28: Interventional Radiology in Trauma
Introduction
Equipment and Devices
Basics
Embolic Agents
Stent-Grafts
Closure Devices
Targets for Endovascular Therapy
REBOA
Head and Neck Vascular Injury
Aortic Injury
Visceral
Spleen
Liver
Renal
Pelvic
Aftercare
Conclusion
References
Part VI: In-Hospital Speciality Care
29: Decision-Making in Damage Control Surgery
Introduction
Definitions
Interpretation of Literature Regarding DCL for Trauma
Selection of Patients for DCL
Preparation for Trauma Laparotomy
Human Factors in Trauma Laparotomy
Situational Awareness
Decision-Making
Communication and Teamwork
Leadership
Summary
References
30: Practical Considerations of Damage Control Laparotomy
Introduction
Universal Actions for Initiating DCL
Optimise Operating Theatre (OT) Setup
Position Patient
Modifications
Snap Brief
Operative Field Preparation
Modifications
RSI
Surgical Access
Surgical Wound Edge Retraction Considerations
Pitfall: Inadequate Exposure
Hostile Abdomen Considerations
First Cavity Actions and Decisions
Communicate Assessment of Findings and Begin Decisions
Top Tip: Two Pairs of Eyes
Empirical Intraperitoneal Packing Sequence Not Required
Alternative Causes of Deranged Physiology
Next Steps
Communicate and Decide
Empirical Intraperitoneal Packing Sequence Required
Further Surgical Manoeuvres: Caval
Further Surgical Manoeuvres: Aortic
Further Risk Mitigation in Aortic Clamping
Further Pack Assessment and Action
Communicate and Decide
Optimise for DCL
Agree When to Remove Packs
Targeted Cavity Actions
Pack Removal
Removing Aortic Occlusion
Futility
Expected Sequelae
Supracolic Compartment and Infracolic Compartment Inspection
Reducing Missed Injuries
Supracolic Compartment
Infracolic Compartment
Actions on Identifying Injury
Closure of the Abdomen with Temporary Intent
Decision on Closure
Method of Temporary Abdominal Closure
Fascial Closure
Laparostomy
Planning a Second Look
Actions on Specific Injuries
Retroperitoneal Haematoma
Anatomy
Principles of Management
Visceral Rotation for Access
Pitfall: Left Medial Visceral Rotation Sub Optimal Technique
Kidneys, Ureter, Bladder (KUB)
Posterior Abdominal Wall Musculature
Summary
References
31: Trauma in the Intensive Care Unit (ICU)
What Is the ICU?
Who Is Admitted to the ICU?
Level 0 Patients
Level 1 Patients
Level 2 Patients
Level 3 Patients
Trauma Patients in the ICU
Initial Assessment & Management
Resuscitation
Hypotension on ICU
Blood Products in ICU
Renal Injury
Secondary & Tertiary Survey
Continued Care
Nutrition
Venous Thromboembolism (VTE) Prophylaxis
Coordinating Further Care
End of Life Care
Conclusion
References
32: Spinal and Neurological Trauma
Introduction
Epidemiology
Classification
Management of Spinal Trauma
Massive Haemorrhage
Airway
Breathing
Circulation
Disability
Transport
Role of Collars in Spinal Cord Trauma
Imaging
Systemic Complications of Spinal Cord Injury
Autonomic Dysreflexia
Thromboembolism
Genitourinary System
Others
Role of Surgery in Patients with SCI
Role of Steroids in SCI
Specific Spinal Injuries
Atlanto Occipital Dislocation
Occipital Condyle Fracture
Atlantoaxial Subluxation
Atlas Fracture
Axis Fracture
Subaxial Cervical Spine Fracture
Thoracolumbar Fracture
Conclusion
References
Further Reading
33: Limb Trauma
Introduction
Understanding the Mechanism of Injury
Assessing a Patient with a Limb Fracture
Assessment of Vascular Injuries
Assessment of Compartment Syndrome
Management of Upper Limb Injuries
Upper Limb-Limb Salvage
Finger Fractures
Carpal Fractures
Radius and Ulnar Fractures
Distal Humeral Fractures
Humeral Shaft Fractures
Management of Lower Limb Fractures
Neck of Femur Fractures
Femoral Shaft Fractures
Inter-Articular Distal Femoral Fracture
Knee Joint Dislocations
Tibial Plateau Fractures
Tibial Shaft Fractures
Distal Tibial Fractures and Pilon Fractures
Foot and Ankle Fractures
Management of Open Fractures
The Management of Bone Loss
Decisions on Amputation or Limb Salvage
Performing a Below Knee Amputation
Osseous Integration
Summary
Bibliography
34: Pelvic Trauma
Introduction
Anatomy
Skeletal Components
Ligaments and Joints
Vascular Anatomy
Classification of Pelvic Fractures
Management of Pelvic Injuries
Initial Interventions
Resuscitation
Haemorrhage Control
Pelvic Packing
Angiography and Embolisation
Fracture Stabilisation
Non-Invasive Stabilisation (Pelvic Binders and Sheet Wrapping)
Emergency Skeletal Stabilisation
Anterior Emergency Fixation
Posterior Emergency Fixation
Definitive Skeletal Stabilisation
Summary
References
Part VII: Special Populations
35: Trauma in Pregnancy
Introduction
Epidemiology
Injury in Pregnancy
Motor Vehicle Accidents (MVA)
Falls
Assaults
Burns
Anatomical and Physiological Changes of Pregnancy
Approach to a Pregnant Trauma Patient
Legal Position of the Fetus
Recognising Pregnancy
Massive Haemorrhage
Airway and Cervical Spine
Breathing
Circulation
Disability
Exposure
Specific Obstetric Complications
Preterm Labour
Placental Abruption
Uterine Rupture
Fetal-Maternal Haemorrhage
Amniotic Fluid Embolism
Maternal Cardiac Arrest
Resuscitative Hysterotomy
Technique for Perimortem Section
Decision to Operate
Preparation
Surgical Technique
Imaging in the Pregnant Patient
X-Rays
Ultrasound
Obstetric Assessment
Patient Management After Trauma
Special Considerations
Pelvic Fractures
Penetrating Injury
Obstetric vs Traumatic Blood Loss
Summary
References
36: Paediatric Trauma
Overview and Epidemiology
Physiological and Anatomical Considerations
Airway
Breathing
Circulation
Disability
Exposure
Assessing the Traumatised Child
Assessing the Child in Trauma
Analgesia
Scoring Systems
Pulses and Blood Pressure
Blood Products
Communication Is Critical with Transfusion
Red Blood Cells
Fresh Frozen Plasma (FFP)
Platelets
Cryoprecipitate
Temperature Control
Head Injuries
Glasgow Coma Scale (GCS)
Injuries, Interventions and Imaging
Immobilisation and C-Spine Control
Spinal Injuries
Truncal Injuries
Access Options
The Use of Imaging in Paediatric Trauma
Mobile Apps
Psychological and Safeguarding Considerations
Parental Involvement
Psychological Input and the Mental Wellbeing of the Team
Safeguarding
Sudden Unexpected Death in Childhood
Conclusions
References
37: Silver Trauma
Introduction
The Physiology of Ageing
Medication and Prescribing in the Elderly
Changes in Assessment of the Elderly Trauma Patient
Mechanisms of Injury
Specific Differences in the Primary Survey
Airway and Cervical Spine
Breathing
Circulation
Disability and Head Injury
Abdominal/Pelvic Injuries
Burns and Extremity Trauma
Safeguarding and Elder Abuse
Blood Management in Elderly Trauma
What Is the Optimum Haemoglobin Concentration?
Anti-Platelet Agents and Their Reversal
Delirium
Respiratory
CNS
Anaesthetics/Analgesia
Infection/Host Defence
Fluid Balance and the Renal System
Gastrointestinal
Rehabilitation and Re-Enablement
Conclusion
References
38: Ballistics and Blast Injury
Introduction
Wound Ballistics
Permanent Cavity
Temporary Cavity
Assessing the Severity of Ballistic Wounds
Blast Pathophysiology
Clinical Priorities
Conclusion
References
Part VIII: Environmental Trauma
39: Immersion and Submersion
Introduction
Epidemiology
Pathophysiology
Immersion vs Submersion
Submersion
Prolonged Submersion and Survival
The Conscious Drowned Patient
Complications of Drowning
Immersion
First 0–3 Minutes of Rapid Immersion: Cold Shock
Next 3–30 Minutes of Immersion: Extremity Cooling
30+ Minutes of Immersion: Hypothermia in Water
Mammalian Dive Reflex
Autonomic Conflict
Rescue from Water
Mud Rescue
Concomitant Injury or Medical Conditions
Infection
Conclusion
References
Further Reading
40: Burns and Thermal Injuries
Hypothermia
Increased Heat Loss
Reduced Heat Production
Physiology of Hypothermia
Staging of Hypothermia
Pre-Hospital Management
Investigations
Treatment
Management of Cardiac Arrest
Cold Injury
Non-freezing Injury: Trench Foot/Frostnip
Freezing Injury: Frostbite
Hyperthermia
Burn Injury
Epidemiology
Types of Burn
Thermal Burns
Chemical Burns
Electrical Burns
Low Voltage Injury
High Voltage Injury
Lightning Strike
Pathophysiology
Burn Area Assessment
Referral Criteria for Specialist Review/Care
Immediate Management
Initial Assessment
Airway and Breathing: Assessment and Management
Airway Injuries Above the Larynx
Airway Injuries Below the Larynx
Carbon Monoxide Poisoning
Cyanide Poisoning
Methemoglobin-Forming Agents
Sulphur Donors
Cobalt Compounds
Circulation
Circumferential Burns
Analgesia
Thermoregulation
Nutrition
Infection
Hypermetabolism
Definitive Management
Longterm Sequalae
Summary
References
41: Environmental Trauma: CBRN Incidents
Introduction
Types of Hazard
General Considerations of CBRN Casualty Care
Casualty Management Within a CBRN Environment
Principles of CBRN Casualty care [6]
Recognition of CBRN Incidents
Safety Considerations
Management of CBRN Casualties
First Aid
Primary Survey (Identification of Life-Threatening Conditions)
Life-Saving Interventions
Casualty Hazard Management
Advanced Medical Care
Rehabilitation
Key Management Points
Chemical Incidents
Chemical Asphyxiants: Including Hydrogen Cyanide and Hydrogen Sulphide (H2S)
Mental Incapacitating Agents (Sedating): Opioids
Mental Incapacitating Agents (Psychotropic): Anticholinergics Including BZ (and Atropine Overdose)
Blistering Agents: Sulphur Mustard
Blistering Agents: E.g. Lewisite [16]
Pulmonary Agents: Including Chlorine, Phosgene, Ammonia, Sulphur Dioxide
Biological Incidents
The Syndromic Approach
Respiratory
Cutaneous
Lymphadenopathy
Gastrointestinal
Haemorrhagic
Neurological: Central
Neurological: Peripheral
Antimicrobial Chemotherapy
Sepsis and Abnormal Host Response to Infection
Radiological and Nuclear Incidents
Ionising Radiation
Nuclear Incidents
Overview of the Management of Radiological Casualties
Decontamination
Exposure and Dosimetry
Acute Radiation Syndrome (ARS)
Treatment of Acute Radiation Syndrome
Localised Radiation Injury
Timing of Surgery
Summary
References
42: Decompression Illness and Diving Medicine
Introduction
What Are the Different Types of Diving?
How Does a Diver’s Physiology Change Whilst Underwater?
Respiratory Adaptations Whilst Diving
Cardiovascular Adaptations Whilst Diving
Gas Mixtures and Diving
Nitrogen Absorption
Factors Influencing the Absorption of Nitrogen
Nitrogen Elimination
Bubble Formation
Decompression Illness
Definitions
Decompression Sickness
Cerebral Arterial Gas Embolism
Presentation of CAGE
Causes of CAGE
Preventing DCI
Management of DCI
Drowning
Introduction
The Pathophysiology of Drowning
Management of the Drowning Diver
Immediate Management of a Drowning Diver
Recognition
Immediate Ascent
In-Water Rescue Breaths
Get to a Surface
The Practical Approach to the Diving Patient for Emergency Medical Services (EMS)
Transfer the Patient to Hospital
Hospital Management
Management in the Emergency Department
Summary
References
Part IX: Post-Incident Care
43: Rehabilitation After Trauma
Learning Outcomes
Introduction
How Is Trauma Rehabilitation Delivered?
Who Is Involved in the Multi-Disciplinary Team?
Specific Areas of Rehabilitation Following Trauma
Musculoskeletal Trauma
Amputee Rehabilitation
Neurological Rehabilitation
Traumatic Brain Injury
Spinal Cord Injury
Lessons from Military Rehabilitation
Conclusion
References
44: Preventing and Treating Trauma-Related Mental Health Problems
Introduction
Immediate and Short-Term Responses to Potentially Traumatic Events
Post-Incident Care: What Should Be Done in the Immediate Aftermath of a Potentially Traumatic Event to Prevent Mental Health Disorders Developing?
Recommendations for Self-Care
Social Support
Recommendations for Trauma-Exposed People: Reaching Out
Recommendations for Those Close to Trauma-Exposed People: How to Communicate
Ongoing Psychological Issues
Post-Traumatic Stress Disorder
Understanding Factors Contributing to Psychological Distress and Disorder
Pre-Traumatic Event Predictors of Mental Health Outcomes
Peri-Traumatic Predictors of Mental Health
Social Support
Post-Event Coping Strategies
Post-Event Impact on Life
Multiple Exposures
Early Detection of Trauma-Related Mental Health Disorders
Treatment of Trauma-Related Mental Health Disorders
Summary
References