1. Major Trauma Team Concept
Ahmed Kamal, FCEM, FRCS
Head of the Emergency Department
Royal Glamorgan Hospital
South Wales. UK
Egyptain Critical Care Summit 12-15 January
2015 Cairo

2. ‫السلمانية‬ ‫قرية‬ ‫أمام‬ ‫باالسكندرية‬ ‫الصحراوي‬ ‫الطريق‬ ‫علي‬ ‫اليوم‬ ‫مصر‬ ‫تاريخ‬ ‫في‬ ‫حادث‬ ‫أسوء‬ ‫وقوع‬
‫أصطدام‬50‫عن‬ ‫يقل‬ ‫ال‬ ‫وما‬ ‫القتلي‬ ‫عشرات‬ ‫وقوع‬ ‫و‬ ‫سيارة‬60‫مصاب‬!
‫يارب‬ ‫ياساتر‬ 27/12/2015
Egyptain Critical Care Summit 12-15 January
2015 Cairo

3. Trains crash
Egyptain Critical Care Summit 12-15 January
2015 Cairo

4. 47 People killed in Egypt Bus crash
Egyptain Critical Care Summit 12-15 January
2015 Cairo

5. Definition (MT)
 Multiple Injuries involving different tissues and organ
systems that are or have the potential to be life
threatening.
 A Major Trauma (or Poly-trauma) is defined as the
Injury Severity Score being:
>15
Egyptain Critical Care Summit 12-15 January
2015 Cairo

6. World Wide
 Leading cause of death under 40.
 5 Million Death / Year = 9% of worldwide death.
 World Bank Report 2011:
 66% Rise in Global Road death over 20 years.
 Reduction 28% in High income countries.
 Increase Up to 147% in 3rd world countries.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

7. Comparison
 Industrialized countries:
– 89% world cars 24% of RTA deaths.
 Developing countries:
– 11% Cars 76%
Egyptain Critical Care Summit 12-15 January
2015 Cairo

8. The UK
 Major Cause of Death in all age group
 16,000 death in England and Wales each year.
 Permanent disabilities
 £3.3 to £3.7 billion
Egyptain Critical Care Summit 12-15 January
2015 Cairo

9. The Central Agency for Public Mobilization and
Statistics (CAPMAS)
 Egypt has the world’s highest traffic accidents rate, according to a
November report by the World Health Organization.
 The number of accidents in 2013 reached 15,000, killing 6,717
people and injuring 2,241 others.
 In 2014 60,000 accidents occurred nationwide leaving 13,000 killed
and injured = 17.6 percent increase
 Nearly 100,000 car accidents took place from 2008 to 2012, leaving
almost 33,000 dead and 155,000 injured, according to a government
report released in March.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

10. The UK
 Major Cause of Death in all age group
 16,000 death in England and Wales each year.
 Permanent disabilities
 £3.3 to £3.7 billion
Egyptain Critical Care Summit 12-15 January
2015 Cairo

11. Egypt Independent: Saturday 03/01/2015
 Losses caused by road accidents reached
– LE17 billion in 2013
– LE20 billion in 2014
= A17.6 percent increase.
“Mr Ali Selim, transportation minister adviser”
Egyptain Critical Care Summit 12-15 January
2015 Cairo

12. Trimodal Distribution of Death:
 50% - 30 minutes.
 30% - 4 hours:
40% -airways obstruction.
40% -Potentially Correctable blood loss.
 20% - days or weeks:
-Sepsis.
-Multiple organ failure.
-PE.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

13. Good Trauma Care involves getting
the patient to:
 At the right time.
 To the right place.
 For the right care.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

14. Time is of the Essence:
Dominique Jean Larrey
Egyptain Critical Care Summit 12-15 January
2015 Cairo

15. Triage of MT:
 Those who are likely to live, regardless of what
care they receive;
 Those who are likely to die, regardless of what
care they receive;
 Those for whom immediate care might make a
positive difference in outcome.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

16. Members of Trauma Team
 ED consultant / ST4 or above Emergency Doc.
 Middle Grade Anaesthetist.
 T & O Registrar
 Surgical Registrar
 Emergency Department F2 Doctor.
 > 4 Nurses
 ODA
 Radiographer
Egyptain Critical Care Summit 12-15 January
2015 Cairo

17. Criteria for Calling MMT:
 Fall>5m
 Pedestrian or cyclist hit by a vehicle.
 >15 % burns ( > 10% in a child)
 > 1 long bone fractured (radius and ulna
on the same side count as 1)
Egyptain Critical Care Summit 12-15 January
2015 Cairo

18. Criteria for Calling MMT:
 Vital signs:
 Respiratory rate > 29 per minute.
 Pulse rate > 130 or < 50 per minute.
 Systolic BP < 90mmHg
 Glasgow Coma Scale <13
Egyptain Critical Care Summit 12-15 January
2015 Cairo

19. Criteria For Trauma Team Call
Trauma calls should be initiated if a patient fulfills any of the criteria below, OR at
the discretion of the Accident and Emergency Department Staff (Nursing or
Medical):
Mechanism Signs & Symptoms
 High-speed motor vehicle
accident
 RTC’s where any of the
following occurred:
- Death of another occupant
of the same car
- Ejection from vehicle
- 2 or more patients incoming
with significant injury
 Penetrating injury to chest,
neck, head, abdomen or groin
 Fall from greater than 6 foot
 An incident with five or more
casualties
 Any gunshot wound
 Burns greater than 15% TBSA
or involving the face
 Traumatic amputation of
anything other than digits
 Significant crush injury
 Reduced GCS
 Actual or potential airway
compromise
 Signs of pneumothorax
 Oxygen saturation of <90%
 LOC >5 minutes
 Pulse >120/minute, or systolic
blood pressure <90mmHg
 Two or more proximal long
bone fractures
 One long bone injury in
association with chest or
abdominal injury
 Flail chest
 Pelvic fracture (not
uncomplicated pubic rami
fractures)
 Spinal injury with neurological
deficit
Paediatric As above, and:
 Capillary refill time > 3 seconds
 A child pedestrian or cyclist hit by any vehicle
 Any concerns regarding mechanism of injury or paediatric observations
 Burns >10% TBSA or facial/ limb circumferential burns.

20. Who else should be informed
 Blood Bank
 On call Radiologist
 Organisation’s Press officer
 Extra staff ? If needed
Egyptain Critical Care Summit 12-15 January
2015 Cairo

21.  Experienced.
 Well lead.
 Organised.
 Aggressive in approach.
 No place for Big egos
 Immediate access to operating Theatres
and Intensive care facility.
Good TT
Egyptain Critical Care Summit 12-15 January
2015 Cairo

22. ASHICE : Ambulance Control
 Age.
 Sex.
 History.
 Injury sustained.
 Condition (GCS).
 Estimated time of
Arrival.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

23. Consequence of Event
 1. Early (AM) Confirmation of team
members details and movement.
 2. Triggering incident.
 3. Senior sister Role.
 4. Call to Switch Board.
 5. Team Arrival as per agreed protocol.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

24. Pay attention to the ambulance sheet : It is a legal
document in court.

27. Team Leader
 Leads but Stands back
 Makes sure that all
members of team are
identified and knows
their tasks.
 Requests investigation
and treatment in order of
priority.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

28. Team Leader
 Assimilates Information.
 Liaises with other speciality.
 Question Ambulance staff.
 Stay calm and reassure members of team.
 May request opinion but ultimate decision
is his.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

29. Team Leader
 Supports and perform difficult procedures
if required.
 Speaks to relatives at various stages.
 Teaching role if situation allows.
 Eventual Evaluation and team summary
Egyptain Critical Care Summit 12-15 January
2015 Cairo

30. Airway Personnel
 Clears and secures airway while taking
appropriate cervical precautions.
 Works as unit with the ODA
 Insert central and arterial lines if required.
 GCS = 8
Egyptain Critical Care Summit 12-15 January
2015 Cairo

31. Circulation personnel
 Establishes peripheral intravenous infusions
and takes blood samples for investigations.
 Pain relief
 Chest drain insertion.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

32. Circulation personnel
 Urinary Catheterisation.
 splinting.
 Carries out other procedures depending on
their skill level.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

33. Nursing
 Assists in the removal of the patient’s clothes.
 Records clinical findings on Trauma chart, lab
results, drugs, vital signs.
 Prepares sterile packs for procedures.
 Brings Extra equipment as necessity.
 Take Care of relatives: in and outside of Resus
room.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

34. Difficulties
 Protocol. Induction
Programme.
 Disorganisation.
 Lack of experience.
 Early recognition of
Potential catastrophe.
 O2, BM and analgesia
( the lack of it) and patient
dignity.
 Personality clash.
 Too Many or too few
( Night time) staff.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

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40. Preparation reduces poor
performance
 People
 Equipment
 Drugs
 Space
Egyptain Critical Care Summit 12-15 January
2015 Cairo

41. Preparation - people
 Assignment of rules by team leader.
– Who will do the primary survey.
– Venus access, taking bloods.
– Who will cut of the clothes.
– Attach the monitor.
– Record of clinical findings.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

42. Preparation - equipment
 Equipment for intubation.
 Chest drain set.
 Pelvic binder.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

43. Drugs
 Drawing up drugs takes time - this will divert the
nursing staff from availability for other tasks.
 Draw up analgesia and antiemetic in advance.
 For predictable intubation – rapid sequence
induction drugs should be ready.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

44. Space
 Arrange space so there is enough room for
easy access.
 Consider:
– Mobile x-ray unit.
– Supporting team to rolling of the patient.
– Relatives space.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

45. It does not hurt to give analgesia
 Reassurance
 Splintage
 Nitrous Oxide
 Opiates
 Ketamine
 Nerve Block
 Intranasal Morphine
Egyptain Critical Care Summit 12-15 January
2015 Cairo

46. Tips
 Pay attention to the Ambulance team.
 A hard collar does not protect the C Spine.
 The spinal Board is really painful.
 Hypotensive Pts get cold fast – cover them.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

47. Tips
 Don’t forget the urinary Catheter.
 Children are not small adults – keep
parents in.
 Head Injury alone does not cause
hypotension.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

48. Tips
 Burned airway requires intubation.
 A penetrating wound below the nipple
involves the abdomen.
 Every ED should have a pelvic binder.
 Don't ignore fracture ribs in the elderly.
 Canadian C-spine for neck.
 NICE Guidelines for HI.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

49. CHILDREN ARE NOT SMALL
ADULTS
 Children regress in age under stress
 Keep relatives close by
 Be aware of common paediatric ONLY conditions.
 Child abuse.
– Physical.
– Emotional.
– Sexual.
– Neglect.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

50. The Canadian C-Spine Rule
 For alert and stable trauma patients where cervical spine injury is a concern
1.Any High-risk factor that mandates
radiography?
Age ≥65 years
Or
Dangerous Mechanism*
Or
Paraesthesia in extremities
2.Any Low-risk factor that allows safe
assessment of range of motion?
Simple rear-end RTC†
Or
Sitting position in ED
Or
Ambulatory at anytime
Or
Delayed onset of neck pain‡
Or
Absence of midline tenderness
NO
Cervical
Spine x-ray
YES
YES
3.Able to actively rotate neck?
45º Left and Right
YES
*Dangerous Mechanisms:
•Fall from ≥ 1m/ 5stairs
•Axial load to head e.g. diving
•RTC high speed, rollover, ejection
•Motorized recreational vehicles
•Bicycle collision
†Simple Rear-end collision MVC excludes:
•Pushed into oncoming traffic
•Hit by bus/large truck
•Rollover
•Hit by High-speed vehicle
Delayed:
Not immediate onset of neck pain
•RTC: Road Traffic Collision
UNABLE
Steil et al. The Canadian C_Spine Rule for Radiography in alert and stable trauma patients. JAMA 2001;286:1841-8
ABLE
No Radiography

51. Trauma Scores : Why?
 Influence direction of Evacuation.
 Quality assurance.
 Allows for comparisons of outcomes
between different hospitals, systems.
 It facilitates a more rational allocation of
resources and manpower.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

52. Trauma Scores
 Anatomical.
– Abbreviated injury scale (AIS)
– Injury severity score (ISS)
 Physiological
– Trauma score (TS)
– Revised Trauma score (RTS)
Egyptain Critical Care Summit 12-15 January
2015 Cairo

53. AIS :Abbreviated Injury Scale
 1200 injuries listed in a booklet.
 Scores from 1 (Minor) – 6 (fatal)
 The higher the score the worse the injury is.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

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55. Injury Severity Score (ISS)
 Maximum is 75 = ( 5² + 5² + 5²)
 ISS < 9 = Minor injury.
 ISS 9-15 = Moderate Injury.
 ISS > 15 = Severe Injury.
 AIS 6 = score 0f 75
Egyptain Critical Care Summit 12-15 January
2015 Cairo

56. Trauma score : 1-16

57. Trauma score and probability of survival:

58. Revised Trauma Score
 Physiological scoring system.
 It is scored from the first set of data obtained on
the patient.
 Consists of:
– GCS
– Systolic Blood Pressure.
– Respiratory Rate.
 High inter-rater reliability.
 demonstrated accuracy in predicting death.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

59. Revised Trauma Score
Egyptain Critical Care Summit 12-15 January
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61. The RTS correlates well with the probability of
survival :
Egyptain Critical Care Summit 12-15 January
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62. TARN
Egyptain Critical Care Summit 12-15 January
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63. Challenges for Egypt
 Road structures.
 Safety at work.
 Executive organisational Network.
 Expertise.
Egyptain Critical Care Summit 12-15 January
2015 Cairo

64. Al Galaa Major Trauma centre:
‫مستشفي‬‫الطوارئ‬ ‫و‬ ‫الحوادث‬‫للقوات‬ ‫الطبي‬ ‫الجال‬ ‫بمجمع‬‫المسلحة‬
Egyptain Critical Care Summit 12-15 January
2015 Cairo

65. Challenges for Egypt
 1. Resources
 2. Resources
 3. Resources
“Dr Mike Clancy – Ex president of CEM when asked about
priorities”
Egyptain Critical Care Summit 12-15 January
2015 Cairo

66. Conclusion
 Functional Pre Hospital Care system
 Early preparation.
 Highly supported protocols.
 Adherence to guidelines.
 Expertise
 Funding
 IT support
Egyptain Critical Care Summit 12-15 January
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67. Egyptain Critical Care Summit 12-15 January
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