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Management of trauma patients in Accident and Emergency

Management of trauma patients in Accident and Emergency. 2012 Data for trauma patients. RTA- 3445 ASSAULT – 2051 FALLS – 1373 BURNS – 913 GUNSHOT -172 RAPE – 60 SNAKE BITES – 31 HUMAN BITES- 30. Challenges.

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Management of trauma patients in Accident and Emergency

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  1. Management of trauma patients in Accident and Emergency

  2. 2012 Data for trauma patients • RTA- 3445 • ASSAULT – 2051 • FALLS – 1373 • BURNS – 913 • GUNSHOT -172 • RAPE – 60 • SNAKE BITES – 31 • HUMAN BITES- 30

  3. Challenges • 34yr old male referred from Machakos D.H. on 13/4/2013 with severe head injury and fracture femur GCS 9/15. • T.O.A 11am seen by the M.O 11am • Hx: Involved in RTA on 12/4/2013 L.O.C, Convulsions, Ottorrhea • O/E:Primary ad secondary survey done • Positive findings: GCS M-4 E-3 V-2 9/15 Blood noted on scalp, ottorrhea R , pupils BERL. Vitals 127/67 P.R

  4. M/S: Deformity on the R thigh (splinted) and L forearm(splinted) • Other systems normal. • Dx: SHI with # R femur/ L Forearm • Plan: CT scan Head and XRAYS (Booked and done at 2pm) • TBC/GXM/U/E/C • Prop up, Oxygen • Phenytoin 750mg loading, 250mg tds • Orthopaedic, neurosurgical and ICU

  5. Orthopaedic review 5pm on 13/4/2013 • GCS E-1 M-5 V-1 7/15 pupils BERL • Xray # proximal radius(closed) • Xray # R femur midshaft • CXR, pelvic xray- normal • Plan: cast radius (done), Traction of femur( thomas splint)

  6. Neurosurgical review 5.25pm • Gcs 7/15 pupils BERL • CT scan: hypodense lession R frontal region • No intracerebral bleed • Conservative management as per Rx sheet • ICU review in view of Low GCS

  7. ICU review 9.15pm • GCs 7/15 pupils BERL • Plan: Oxgen by non-rebreather mask 15L/min to be intubated once there is a free ventilator. • Patient intubated at 11.00pm

  8. Patient was on a stretcher in Acute room from 13th to 15th when he was admitted in Emergency ward (Lack of beds). • Currently patient admitted in Emergency ward. • ICU team reviews the patient daily.

  9. Issues • Delay in review of patients by the various disciplines. • Lack of teamwork in the management of the patients. • Lack of ownership of the patient. • Delay at the radiology department

  10. Lack of resources i.e. human, equipment (bed space, ventilators) • Congestion of casualty by catchment area. • Shortage of personnel especially nurses, porters and doctors. • Locum doctors- young doctors with minimal experience, lack of commitment.

  11. Trauma theatre and ward have not been in use for the past 5 years thus the trauma patients miss the golden hour to be attended to hence develop complications eg infections etc.

  12. Way forward • Introduction of a trauma nurse coordinator who follows up on all trauma patients in casualty. • Have the sitting surgeon review the trauma patients immediately on arrival and decide on definitive management. • Have an x-ray room specifically assigned to accident and emergency department.

  13. Have trauma theatres available for trauma patients on 24hr basis i.e. with personnel posted to the theatres at A&E on 24 hr basis. • Consultants should be available in order to supervise SHOs and guide them in decision making.

  14. Strengthen existing triage system in Emergency Department • Train personnel on emergency ultrasonography and avail ultrasound machine for department for Focused Ultrasonography for Trauma patients.

  15. Adopt clinical protocols and adhere to them in a multidisciplinary approach to patient care. • ATLS training for both nurses and doctors working in the department. • Have more staff deployed to the department. Currently we have 103 nurses instead of 195 and 13 doctors instead of 36.

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