An algorithm is an illustration of a series of medical decisions that address certain patient specific conditions outlining appropriate responses intended to lead to an outcome.
The goals of an algorithm are to identify diagnostic alternatives, treatment options, and outcomes by weighing decision benefits against risks and costs.
These algorithms can be explicit and published based on best evidence such as in Fig. 1 or individual critical decision making based on expertise and experience.
Decision pathways reach knots or nodes, from which several options are available.
A primary benefit of a well – developed algorithm is that it focuses the reader on the critical decision points in any clinical scenario and specifically lists the input data that leads to a decision. Algorithms can be applied to specific problems, processes, or diseases. They allow for evolution of a disease related topic with new information or clinical conditions that may affect decision making later in the time course of a situation. They can convey the scope of a clinical condition from presentation, through testing and assessment, followed by a clinical judgment and action leading to an eventual outcome. Annotations are added to appropriate points on the algorithm and are necessary for all decision nodes. The purpose of the annotation is to explain all critical factors affecting decisions in as concise a manner as possible. The primary advantage of an algorithm is that it can summarize an evidence based guideline into an easily and quickly available practice protocol for use in the clinical care setting. Fig. 1 is an example of such an algorithm published by the Western Trauma Association.
WTA Pelvic fracture management algorithm.
In countries such as Australia which have very low volume of GSWs to the abdomen, there is a lower threshold for explorative laparotomy versus selective conservatism. The latter may involve observation for peritonism/bleeding and/or performing CT to look for tangential injury without peritoneal violation as is done in high penetrating GSW volume North American trauma centres. CT can be used to ascertain bullet trajectory and can assist in detecting retroperitoneal injury.
In general, management of GSWs such be based on objective physical examination, findings and diagnostic investigations and not on entry and exit sites or sizes.
Retrieved bullet
There are only a few indications to retrieve the bullet. These include bullets found in joints, CSF, or the globe of the eye. Fragments leading to impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed. Rare indications are lead poisoning caused by a fragment, and removal that is required for a medico-legal examination. In all other cases the indication should be critically reviewed.
Many prehospital teams carry refrigerated blood. This can be warmed with the Buddy Lite (Fig. 3). The Buddy Lite can heat 4.4 liters of fluid or blood to 38°C on a single charge. Its major limitation is that it is unable unable to heat fluid that is given rapidly.
As well as ordering INR/aPTT all major trauma patients suspected of bleeding should have fibrinogen level sent. Hyperfibrinolysis in major trauma (detected by fibrinogen level/viscoelastic tests) is associated with worse outcomes. It is treated with cryoprecipitate transfusion.
Belmont buddy Lite fluid warmer
‘Code Crimson’ is a term that has commonly been used by hospital-based teams managing patients with life-threatening haemorrhage that is refractory to resuscitation. The purpose of a ‘Code Crimson’ activation is to streamline patient access to definitive intervention, including an operating theatre or interventional radiology suite. This has recently been formalised in NSW and can be activated by prehospital teams.
Patients who fail aWPTAS with brain injury and who do not have a surgically evacuable intra-cranial lesion are at high risk of suboptimal management. Amnesia is only one symptom and symptoms may also include fatigue, dizziness, headache, cognitive and psychosocial changes. These patients may acutely require referral for in-patient Brain Injury Unit management prior to rehabilitation.
With Sydney temperatures consistently reaching the high 30’s and early 40’s recently it is perhaps timely to revise heat related illness. It is also worth considering the steps we can take to keep ourselves cool in the same environmental conditions.
Heat related illness covers a spectrum which, at the most extreme end, includes heat stroke. This is defined as hyperthermia >40 degrees, associated with neurological dysfunction. The neurological dysfunction can manifest in many ways including ataxia, delirium, seizures and coma. The patient may also be tachycardic and hypotensive (echo may show either a hypodynamic or hyperdynamic LV). Sweating may be absent. Unrecognised heat stroke carries a mortality of up to 30%.
Management
Aggressive cooling in the field can prevent a cascade of organ dysfunction and significantly improve prognosis. Initial management and cooling methods will be dictated by resources and environment but consider:
Don’t forget standard resuscitation measures:
A = RSI if patient is obtunded and unable to protect airway
B = Ventilate as required. Be aware that pulmonary oedema and ARDS may accompany heat stroke if you are having difficulty ventilating
C = iv fluids may be needed but don’t equate hyperthermia with hypovolaemia. Depending on clinical circumstances, the patient may be either mildly or profoundly volume depleted. Be aware of dilutional hyponatraemia in endurance athletes consuming lots of sports drinks. This can be an important differential for altered LOC and seizures.
Inotropes may be required if shock is refractory to fluid resuscitation but be aware that adrenaline and noradrenaline will cause vasoconstriction that may impair cooling.
D = Benzodiazepines for seizures, don’t forget to check a BSL
Self Care
Self-care is important on these missions as crew members are being exposed to the same environmental conditions as the patient and may have had to exert themselves to get there (winch, bush walk etc.) Make sure you are well hydrated pre mission and carry additional water. Urine colour is the best guide to your hydration status. Ice packs are available in the ready room and can be used by crew if needed. Consider your uniform sunhat if your head is exposed. Sun cream is also available in the ready room. If you are feeling unwell due to heat, communicate this immediately to your crew.
A significant number of our critical care patients are dependent on vasoactive drugs, so it is worth reviewing the process for managing these infusions during inter-hospital transfers.
The priming volume of the distal lumen of a central line is 0.44mls. Therefore an infusion running at 10mls / hour could take approximately 3 minutes to reach the patient if started de novo. The half-life of inotropes such as adrenaline and noradrenaline is short, approximately 1 minute. This leaves the patient vulnerable to a period of hypotension. Corrective bolusing of vasoactive drugs is not recommended as it can lead to large, and potentially detrimental, swings in blood pressure. Therefore a smooth transition between syringe pumps is recommended to maintain haemodynamic stability.
There are a number of different methods for double pumping but one suggested protocol is as follows:
Tips and tricks
Further reading:
Management of the changeover of inotrope infusions in childrenIntensive and Critical Care Nursing 2004 ArinoChangeovers of vasoactive drug infusion pumps impact of a quality improvement programCritical Care 2007 Argaud
The following learning points are collated from Regional and Rural hospitals of NSW, Australia, represented here by a single fictional institution – Umbara Base Hospital. Cases are amalgamated and anonymised (including alteration of patient demographics) such that similarity to real patients is coincidental.
Below are some high-yield learning points collated from the Umbara Hospital trauma case review meeting.
Patients with blunt trauma with significant orthopaedic injury may have other significant other injuries that are difficult to assess on history and examination and easy to miss.
Here’s a good article on this.
Anchoring bias may also occur, particularly in inter-hospital transfers. These are higher risk patients for missed/delayed diagnosis. Reassess the patient from the start.
Elderly patients (>65) who sustain blunt chest trauma with rib fractures have twice the mortality and thoracic morbidity of younger patients with similar injuries. For each additional rib fracture in the elderly, mortality increases by 19% and the risk of pneumonia by 27%.
CXR is inaccurate in diagnosing the presence and number of rib fractures – hence we should have a low threshold for CT to further assess. Current best practice is the ChIP protocol.
Angioembolisation in renal trauma is effective in selected patients.
Trauma CT: Blue arrow is contrast ‘blush’=active bleeding point. Red arrow is perinephric haematoma.
Angioembolisation. Red arrow=coils in arcuate artery of kidney which has stopped the bleeding.
When transferring these patients from smaller hospitals to larger centres, consider whether initial destination should be the ED for rapid re-assessment prior to entering IR suite.
Anterior and posterior ‘cardiac box’
Penetrating trauma to the ‘cardiac box’ may result in cardiac injury and pericardial effusion leading to tamponade. A permissive hypotension strategy is followed where practical.
Diagnosis may be made by eFAST, bedside formal echo or by CT depending on clinical stability.
Axial CT showing anterior pericardial effusion (blood) from trauma (blue arrow)
Pericardial fat stranding caused by pericardial blood (red arrow)
The key operative finding at the tertiary trauma centre was right ventricle laceration, which was successfully repaired.
The following learning points are collated from Regional and Rural hospitals of NSW, Australia, represented here by a single fictional institution – Umbara Base Hospital. Cases are amalgamated and anonymised (including alteration of patient demographics) such that similarity to real patients is coincidental.
Below are some high-yield learning points collated from the Umbara Hospital trauma case review meeting.
Always check the chest drain with a CXR – particularly check for the drain’s position and for complications such as kinking, as can be seen in this left sided CXR.
Pneumothorax is often associated with subcutaneous emphysema (free air in the tissues under the skin). It feels like bubble-wrap and looks like this on CT. Don’t press too hard though – it’s likely there are rib fractures underlying the air and they are extremely painful!
Trauma in older patients is increasing with our ageing population here in Umbara – ever improving management of chronic health conditions means people are living longer. It is difficult to predict mortality in elderly trauma and hence some scoring systems exist.
Geriatric Trauma Outcome: Age + (2.5x ISS) + 22 (if PRBCs administered)
Mortality: 205=75%, 233=90%, %, 252= 95%, 310=99%.
These scoring systems may help guide discussions with patients and their families in the future.
Data from the UK Trauma Audit and Research Network (TARN) showed that 2.5% of children in their database had suspected child abuse underlying their injuries. 97.7% of these children were aged <5yrs; 76.3% were aged <1yr. Injury severity score (ISS) was also greater in patients with suspected child abuse: they were 1.7x as likely to have an ISS score >15.
You can read more in this free-to-access paper.
IDENTIFY risk factors through history, examination, observation.
LISTEN and watch parent-child interaction
CONSIDER the possibility
DON’T DISMISS non-accidental injury as a possibility due to lack of physical findings
DOCUMENT carefully, clearly and contemporaneously
PREVENT by linking with services
KNOW your legal requirements for reporting
Although non-accidental injury can occur in the absence of these factors, there are several factors which have associations with non-accidental injury.
In the child:
Parent/Family:
Other concerning features:
Clinical/Attendance features:
Child Protection Courses: http://www.heti.nsw.gov.au/Courses/Child-Protection/
Non-accidental injury blog & podcast: http://stemlynsblog.org/child-protection/
When Umbara Base Hospital’s own Dr Tallie fell from her horse earlier this month and ended up being treated in her own Emergency Department, she was in a unique position in being able to provide constructive feedback around her own care with a full understanding of the processes of the hospital.
This month we invited her to share her thoughts at the trauma case review meeting and were delighted to learn the following.
Huge thanks to Dr Tallie for her insights – we wish her well on her recovery.
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