Anaesthesia, Trauma and Critical Care Course Manual 2014

460 Pages·2014·7.14 MB·English

Anaesthesia, Trauma and Critical Care
Course Manual 2014
Frontmatter
Editors
Dr Mark Forrest
BSc Hons MB ChB FRCA FICM
Consultant in Anaesthetics, Critical and Prehospital Care
Warrington & Halton Hospitals NHS Foundation Trust
ATACC Medical Director
Medical Director NW Police Firearms Collaboration
Cheshire Fire & Rescue Service Medical Director
UK
Dr Peter Lax
MB ChB (Hons.), Dip RTM, Dip IMC RCSEd, FRCA, RAF
Squadron Leader
Anaesthetics/Intensive Care Medicine SpR, Royal Air Force Critical Care Air Support Team
Tactical Medical Wing, RAF Brize Norton, Oxfordshire
UK
Dr Jason van der Velde
BAA, MBChB, M.Sc. (DM), MCEM
Prehospital Emergency Medicine and Critical Care Retrieval Physician
Clinical Lead HSE National 24 hour Emergency Telemedical Support Unit
Cork University Hospital
ATACC Assistant Medical Director
West Cork Rapid Response Medical Director
Ireland
i
Contributors
Dr Carin Dear Consultant Anaesthesia and Prehospital Care, Southampton MTC, UK
Dr Hugh Doran GP and Prehospital Emergency Medicine, East Cork, Ireland
Mr Ian Dunbar International Extrication & Rescue Specialist, Holmatro, Holland
Dr John Glasheen Critical Care Retrieval Physician, Sydney HEMS, Australia
Ms Jennie Grainger Surgical SpR, RCS link, Cheshire, UK
Dr Peter Larcombe Consultant Anaesthetist and Neuro Intensive Care, Brighton MTC, UK
Prof Mike Mcnicholas Trauma & Orthopaedic Surgeon, Aintree MTC, UK
Dr Jenny Parsons Anaesthetics and Intensive Care SpR, Dundee, Scotland
Dr Geoff Roberts Deputy Coroner, Cheshire, UK
Dr Phil Russell SpR Anaesthetics and Prehospital Emergency Medicine, UK
Mr Noaman Sarfraz Consultant Surgeon, Pakistan Army (Ret), Cheshire, UK
Paul Savage OBE Clinical Operations Manager RNLI, Chairman UKSAR Medical Group
Dr Marc Scott Senior Consultant Anaesthetist, Amsterdam Medical Centre, Holland
Miss Brigid Wall Advanced Paramedic, Queensland Ambulance Service, Australia
Dr Craig Williams Consultant Anaesthetics and Intensive Care, Swansea, Wales
Mr Lee Winterbottom Paramedic, Course Director, Frontier Medex, UK
Ms Dawn Wood Senior NHS Manager, Trauma & Orthopaedics, Cheshire, UK
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Copyright
© 2014 The ATACC Group
All rights reserved. This book or any portion thereof is to be treated as FOAMed and

may not be reproduced or used in any manner whatsoever for commercial gain without
the express written permission of the Authors except for the use of brief quotations in a
book review.
Published by The ATACC Group
Eighth Edition, 2014
PDF Version
ISBN 978-0-9930618-1-3
ATACC OFFICE
C/O ANAESTHETICS DEPARTMENT
LOVELY LANE
WARRINGTON
WA5 1QG
UK
@ATACCFaculty
[email protected]
www.atacc.co.uk
iii
Foreword and FOAMed
Welcome to the new ATACC ‘Virtual’ aware, this is the first Virtual Textbook in
trauma manual. All six editions of our previ- the FOAM community and we are hugely
ous manual have been a printed text and excited about its potential.
whilst far more current than many tradi-
As it stands we know that it is still not per-
tional texts, we were always left somewhat
fect and as such this will be an on-going
frustrated that once it had reached print,
project. We aim to keep the text as current
that elements were already out of date.
as possible with regular re-writes and up-
15 years ago, ATACC made a commitment dates in response to new research, best
to be as up to date as we possibly could practice and feedback from the FOAM
be and we constantly update our lectures community. We hope that you embrace it
and educational content. We have also and support it with your comments.
been committed to utilising every new edu-
We also hope that it will encourage many
cational modality or tool and this continues
individuals to come and see how on the
with our increasingly immersive simula-
course we bring together the knowledge
tions and innovative skill stations.
with the safe, practical delivery of high
In this manner the world of FOAMed (Free quality trauma care. It may also inspire oth-
Open Access Meducation) has given us ers to develop their own local up to date
the ideal platform and opportunity for us to training courses, moving away from out-
similarly update our manual and textbook dated tick box courses.
content and as a non-commercial body,
Enjoy the text and we would be delighted
ATACC can launch this into the open forum
to receive feedback, comment and discus-
of the FOAM community, with free access
sion as this is very much a ‘work in pro-
to all.
gress’ and will continue to evolve and im-
Whilst there are many outstanding blogs, prove. We will also hopefully see you on an
Twitter feeds and podcasts that we all fol- ATACC course very soon!
low on a regular basis, as far as we are
iv
Table of Contents
N.B. Due to formatting differences between the iBooks and PDF versions of the manual
the page numbers below refer to pages as viewed in your PDF viewer, which are usually
one higher than the numbers displayed on the pages themselves.
Section 1: Introduction to ATACC
Welcome to the Virtual ATACC Manual Page 9
Royal College of Surgeons Page 14
Section 2: Trauma Care Delivery
Roadside to Critical Care Page 18
Team Approach Page 40
Section 3: Prehospital Care
The Speciality Page 62
Mechanism of Injury Page 64
Safe Approach Page 75
Mass Casualty Management Page 92
Road Traffic Collision Extrication Page 98
Trauma Retrieval Page 112
Section 4: Initial Management
Massive Haemorrhage Control Page 130
Airway Page 144
Respiration Page 176
Circulation - Shock and Traumatic Bleeding Page 203
Head Injury Page 228
Traumatic Cardiac Arrest Page 239
v
Table of Contents
Section 5: Ongoing Trauma Care
Initial Approach to Damage Control Resuscitation Page 249
Trauma Team Receiving Care Page 261
Analgesia Page 269
Trauma Induced Coagulopathy Page 292
In-hospital Damage Control Resuscitation Page 315
Section 6: Specialist Care
Thoracic Trauma Page 336
Neurosurgical Intensive Care Page 348
Spinal Trauma Page 353
Musculoskeletal Trauma Page 371
Trauma in Pregnancy Page 400
Section 7: Environmental Trauma
Tactical Medicine Page 408
Decompression Illness Page 427
Immersion and Submersion Page 429
Thermal Injuries Page 440
vi
1
Introduction to ATACC “Above all we have to go beyond
words and images and con-
cepts. No imaginative vision or
conceptual framework is ade-
quate to the great reality”
– Bede Griffiths
Welcome to the Virtual measurable improvement. In the UK, de-
spite several reports in the past and more
ATACC Manual
recently the 2007 NCEPOD ‘Trauma Who
8th edition: 2014
Cares’ document and the subsequent Na-
tional Audit Office 2011 report, it was clear
that despite increasing levels of ATLS train-
Trauma remains one of the major killers in
ing, improvements in paramedic skill sets,
our modern society. Improved medical
greater understanding of the complexities
care enables us to sustain life in the face
of trauma and recent wartime medical ex-
of many serious conditions but until we
perience, little had actually improved in
reach 40-50 years of age, trauma is the
terms of outcome.
greatest risk to life.
What was required was a national struc-
If we total up all of the lost life years, from
ture for managing trauma and also training
cancer, heart disease and stroke prema-
that moved rapidly with the times, which
ture deaths, then it will still not be equiva-
could easily be adapted, modified and en-
lent to the number lost as a result of
hanced as knowledge expanded. From
trauma. It is a killer of all age groups, but
this the UK National Trauma Network was
especially the young.
established and modern trauma courses
such as ATACC, European Trauma Course
Even for survivors, without delivery of a
and the Emergency Trauma Medicine
high standard of care, at the earliest oppor-
course became far more popular, offering
tunity, they can be left with severe life-
a far more current and advanced level of
changing long term disability. As a result
training, including newer concepts and
the impact on patients, families, the health
methods, such as effective crew resource
service and us all, can be considerable
management.
with huge costs to everyone.
Since 1997, ATACC has gone to consider-
In light of these facts there is a constant
able lengths to keep our course as up to
drive to improve trauma care standards,
date as possible and the educational con-
but for many years there was little real
8
tent is reviewed and updated between History
every single course. As such, it remains Back in 1997, Dr Mark Forrest was ap-
academically far ahead of many rival proached by the Head of the Mersey
courses and the Faculty are always keen School of Anaesthesia to address the is-
to here of anything new that enthusiastic sue of trauma training for the local anaes-
candidates may have also seen or read. thetic & critical care community.
In many areas of trauma, we are still far As an ATLS instructor he realised that
from having all the answers and no area is there were many very good qualities to this
a better demonstration than that of trauma course, but it was Americanised, surgically
induced coagulopathy. We now under- biased and it was proving difficult for it to
stand far more about coagulation in keep up with the changes and develop-
trauma, but it just seems to complicate the ments that were occurring within trauma
whole picture still further, without providing practice. To be fair ATLS aimed to do noth-
all of the necessary answers or solutions. ing more than provide a robust back-
This is typical of many aspects of trauma ground of trauma skills for clinicians who
care and presents courses and instructors may face major trauma on an infrequent ba-
with a dilemma, as there is often no clear sis and have to manage it in a systematic
answer to many questions. Faced with fashion as part of a trauma team.
such challenges, some courses just sim-
It was never designed to be the course for
plify the issue and offer an old or basic so-
leading major trauma centres and as such
lution, whereas ATACC will do its utmost to
‘advanced’ may not be the best title, but
present all of the current best evidence
as an initial introduction it was a good
and then suggest what we consider the
start. Sadly, as our approach to trauma
best current solution, often just based on
has progressed, a number of the methods
the educated opinions of key players in
and principles of ATLS have proved incor-
trauma in the UK and around the world.
rect, but these were slow to be changed,
The ATACC Faculty aim to offer the latest resulting in many disillusioned candidates
and most advanced trauma methods, and Faculty members. As such ATACC of-
taught in a stimulating and innovative man- fered a fresh alternative, with s similar ap-
ner, using all the modalities that we can to proach but an ongoing commitment to up-
develop team skills, trauma skills and an date the educational material before every
appreciation of relevant human factors. course. Over the last 15 years the Faculty
9