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Surgery SC083: Trauma Evaluation And Management (TEAM) Flashcards

1
Q

TEAM, Goals / Principles of Trauma Care

A

TEAM: Trauma Evaluation and Management

Goals:

  1. Rapid, accurate, physiologic assessment
  2. Resuscitate, stabilise, monitor by priority
  3. Prepare for transfer to definitive care
  4. Team work for optimal, safe patient care
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2
Q

Need for Early TEAM

A
  • Leading cause of death from 1-44 yo
  • Disabilities exceed deaths by ratio of 3:1
  • Trauma-related costs >$400 billion per year
  • Lack of public awareness for injury prevention
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3
Q

Injury Prevention (ABCDE)

A

ABCDE:

  1. Analyse injury data
  2. Build local coalitions
  3. Communicate the problem
  4. Develop prevention activities
  5. Evaluate the interventions
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4
Q

Trimodal death distribution of trauma

A
  1. Immediate deaths (death at scene)
    - most patients
    - **airway compromises, **C-spine injuries, ***breathing: pneumothorax, haemothorax, hypoxia
    - need prevention from policies
  2. Early deaths (2 hours after injury)
    - **bleeding: “Blood on the floor and Four more”
    —> On the floor: Bleeding from visible wound
    —> Four more: Chest, Abdomen, Pelvis, Fractured long bone (e.g. femur)
    - preventable by **    golden hour management + early transfer to appropriate care
  3. Late deaths (A few weeks later)
    - usually due to surgical complications e.g. multiorgan failure, pneumonia (preventable by ICU care), renal failure, sepsis, UTI, aspiration, post-op complications
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5
Q

TEAM Principles

A
  1. Treat greatest threat to life first
    - Secure Airway, C-spine —> then treat Breathing (e.g. pneumothorax, give O2) —> Circulation (e.g. give fluid)
  2. Definitive diagnosis less important
  3. Physiologic approach
    - correct any aberrant physiology first then getting the diagnosis
  4. Time is of the essence
  5. Do no further harm
  6. Teamwork required for TEAM to succeed
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6
Q

TEAM members

A
  1. Team leader
  2. Airway manager
  3. Nurse
  4. Assistant x2

Trauma call:

  1. Surgeon
  2. Junior surgeon
  3. Anaesthetist
  4. AED physician
  5. Orthopaedic surgeon
  6. Neurosurgeon (if head injury, reduced consciousness)
  7. Nurse
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7
Q

Pre-hospital preparation and In-hospital preparation

A

Pre-hospital preparation:

  • Closest, appropriate facility
  • Transport guidelines / protocols
  • On-line medical direction
  • Mobilisation of resources
  • Periodic review of care

In-hospital preparation:

  • Pre-planning essential
  • Team approach
  • ***Trained personnel
  • ***Proper equipment (e.g. ETT tube, Laryngoscope, Bag-valve mask, Fluids, IV cannula)
  • ***Environment (e.g. Resuscitation room)
  • Lab / X-ray capabilities
  • Standard precautions (cap, gown, gloves, mask, shoe covers, goggles / face shield)
  • Transfer agreements
  • Quality Improvement (QI) program
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8
Q

Triage

A

Sorting of patients according to:

  • ABCDE
  • Available resources
  • Other factors e.g. Salvageability
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9
Q

TEAM Sequence

A
  1. Primary Survey + Resuscitation of vital functions
    - ABCDE
    - Adjuncts
    —> Pulse oximeter
    —> Capnography (end-tidal CO2)
    —> BP monitor
    —> ABG
    —> ECG
    —> Urinary catheter for Urine output (aim ***0.5 ml/kg/hr)
    —> X-ray (Chest (pneumothorax, broken ribs, mediastinum, diaphragm, lung shadows, soft tissues, placement of chest tubes), C-spine, Pelvis)
    —> FAST scan (Pelvis, Perihepatic (Morrison’s pouch X look at parenchyma), Perisplenic / Splenorenal recess, Subxiphoid for pericardium)
    —> DPL
    —> Orogastric tube to decompress stomach / prevent aspiration (unless confident no head trauma —> NG tube)
    —> Take blood: CBC, Cross match, Type and Screen etc.
  2. Secondary survey + Re-evaluation of vital functions
    - Head-to-toe examination (skeletal survey, CT, log-roll to see the back)
    - Adjuncts
  3. Continuous re-evaluation
  4. Safe transfer
  5. Definitive care
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10
Q

***Primary survey (ABCDE)

A
  • **ABCDE:
    1. Airway with C-spine protection
  • ask for the name: A: patent airway, B: some degree of breathing, C: adequate cerebral perfusion, D: not confused
  • assess airway patency
  • hoarseness, stridor, snoring, gurgling, rocking chest wall motions, charcoal particles (if burn)
  • maxillofacial trauma / laryngeal injury
  • C-spine injury
  1. Breathing / Ventilation / Oxygenation / Life-threatening chest injury
    - noisy breathing
    - tracheal deviation
    - auscultate chest
    - foreign body / blood in airway
    - signs of pneumothorax —> chest tube to decompress
    (- chest rise, symmetry, expansion pattern (Kussmaul?)
    - air entry
    - RR / Effort
    - SaO2
    - accessory muscles
    - tracheal position
    - central cyanosis
    - sensorium (hypoxic, confused, AMS)
    - diaphoresis
    - chest wall injury
    - JVP)
  2. Circulation / Stop the bleeding
    - large bore IV access (>16F) —> IV fluid (warm crystalloid) to resuscitate / volume replacement —> up to ***1L initially for adults —> if no response —> give blood
    - large intraabdominal bleeding —> emergency laparotomy
    (- monitor BP / P / ECG)
  3. Disability (Neurological status) / Intracranial mass lesion (e.g. ICH)
    - pupillary responses
    - GCS score (Comatose: <8: need intubation)
  4. Exposure / Environment / Body temp
    - room temperature should be high enough
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11
Q

***Adjuncts

A
  1. Take blood
    - CBC
    - LRFT
    - ***Cross match / Type and Screen
    - Clotting
    - Glucose
    - Amylase
    - Toxicology: Alcohol, Paracetamol, Salicylate
    - Pregnancy test in child-bearing age women
  2. **Urinary catheter
    - Blood?
    - Decompress bladder
    - Monitor urine output (aim **    0.5 ml/kg/hr)
    - Caution: pelvic fracture, blood at urethral meatus, ecchymosis at perineum, high-riding prostate
  3. Gastric catheter / ***Orogastric tube
    - Blood / bile?
    - Decompress stomach
    - Caution: skull base fracture (CSF rhinorrhea / otorrhoea, periorbital ecchymosis, mid-face instability, haemotympanum)
  4. ***Monitor
    - Vital signs
    - ABG
    - ECG
    - Pulse oximeter
    - End-tidal CO2
  5. **Diagnostic tool
    - **    X-ray: Chest / Pelvic / C-spine (not compulsory ∵ CT scan available now)
    —> CXR: pneumothorax, broken ribs, mediastinum, diaphragm, lung shadows, soft tissues, placement of chest tubes
    - ***FAST —> Pelvis, Perihepatic (Morrison’s pouch X look at parenchyma), Perisplenic / Splenorenal recess, Subxiphoid for pericardium (may miss retroperitoneal space e.g. haematoma around kidneys / aorta but not rupture into peritoneal cavity)
    - DPL (not use now)
    - CT scan (ONLY when haemodynamically stable)
  6. Consider need for transfer
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12
Q

Decision making

A

Haemodynamically normal patients:
- ***ample time for full evaluation of patients to decide on treatment strategy

Haemodynamically stable patients:
- investigations aiming at establishing ***source of bleeding + whether the bleeding stops

Haemodynamically unstable patients:
- CT not possible (contraindicated)
- FAST scan: operator dependent, good at identifying intra-abdominal free fluid (e.g. blood)
- DPL: accurate, fast, negative finding in shock patients —> may signify retroperitoneal bleeding
Positive DPL:
—> presence of bowel content / frank blood
—> RBC >=100,000
—> Unspun specimen WCC >=500

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13
Q

Resuscitation: Airway

A
  1. Chin lift / Modifed jaw thrust
    - No head tilt to maintain C-spine immobilisation
  2. Look, listen, feel
    - obstruction (foreign body, loose teeth, vomitus)
    - laryngeal deformities
  3. Remove particulate matter
  4. Definitive airway as necessary
    - Intubate if necessary (see indications next slide) —> monitor with end-tidal CO2
    - ETT
    - Airway adjuncts: OPA
    - Cricoid pressure: prevent aspiration
    - Cricothyroidotomy
  5. Reassess frequently
    - e.g. inhalational burn injury —> swollen airway
  6. Protect C-spine
    - neutral position of head and neck with bimanual in-line stabilisation

(7. Medications
- BDZ, Opioid, Short-acting muscle relaxants)

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14
Q

Indications for Intubation

A
  1. Airway problems
    - Obstruction (e.g. facial injury, burns)
    - GCS <=8
  2. Breathing problems
    - Paralysis: Spinal injury, Drug-induced
    - GCS <=8
    - Apnea
    - CO2 retention with respiratory acidosis
    - Hypoxaemia
    - Haemodynamic instability
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15
Q

Resuscitation: Breathing

A
  1. Observe
    - Chest rise, symmetry, expansion pattern (Kussmaul?)
    - Air entry
    - RR / Effort
    - SaO2
    - Accessory muscles
    - Tracheal position
    - Central cyanosis
    - Sensorium (hypoxic, confused, AMS)
    - Diaphoresis
    - Chest wall injury
    - JVP
  2. Supplemental O2
    - High flow O2 (even for COAD patients —> if too much O2 inhibit respiratory drive —> simply mechanically ventilate —> so don’t worry)
  3. Ventilate as needed
    - Variable performance device: Facial mask
    - Fixed performance device: Venturi mask, Ventilator
    - Monitor with end-tidal CO2
    - Minute volume: 6-8L (8-10 ml/kg BW)
    - Frequency: 12-14 / min
    - ***Avoid hyperventilation + Ensure PaCO2 35-40mmHg —> Avoid respiratory alkalosis —> left shift of O2 dissociation curve —> ↑ Hb O2 affinity + ↓ tissue O2 availability
  4. Tension / Open pneumothorax —> tackled in Primary survey
    - Tension pneumothorax: needle then chest tube decompression (size 16, 8 cm, 5th ICS, MAL)
    - Open pneumothorax: occlusive 3 sided dressing
  5. Reassess frequently
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16
Q

Resuscitation: Circulation

A
  1. Haemorrhagic shock (until proven otherwise)
    - Blood on the floor + Four more
    - **External: Apply direct pressure / tourniquet (need to mark down time of putting on, do not release until arrive hospital / OT)
    —> avoid blind clamping
    - **    Internal: Chest, Abdomen, Pelvis, Retroperitoneum
    —> pelvic binder, rotate ankles internally to further decrease size of pelvis
    —> interventional embolisation
    —> +ve FAST scan (large intraabdominal bleeding) —> emergency laparotomy
    —> -ve FAST scan —> review other causes of shock + CT for retroperitoneal haemorrhage
    - ***Long bone fracture: Traction splint
    - Identify: history, P/E, investigations
  2. Non-haemorrhagic shock
    - Cardiac tamponade —> Pericardiocentesis + Direct operative repair
    - Tension pneumothorax —> Needle decompression + Tube thoracostomy
    - Massive haemothorax —> Volume resuscitation + Tube thoracostomy
    - Neurogenic shock (rare) (cardinal feature: warm periphery vs cold clammy in haemorrhagic shock (bradycardia may still been seen in ↑ICP, ∴ not cardinal feature))
    - Septic (late complication)
  3. Assess organ perfusion
    - level of consciousness
    - skin colour
    - pulse rate, character
    - have to stop bleeding!!! —> if simply give fluid to maintain adequate BP —> bleeding may ↑ with ↑ BP
    - maintain reasonable BP before operation —> maintain adequate cerebral perfusion but not too high BP —> ***normotension before definitive measures may cause more bleeding

S/S:

  • Tachycardia
  • Vasoconstriction
  • ↓ CO
  • Narrow pulse pressure
  • ↓ MAP
  • ↓ Blood flow

Caution:

  • Children (lower BP generally)
  • Elderly (higher BP generally)
  • Athletes (may be bradycadic originally)
  • Pregnancy (hypervolaemic)
  • Medications
  1. Large IV bore access
    - **x2 on each arm
    - **    Size >16
    - **Warm IV fluid (Ringer’s lactate / Normal saline)
    - **    1-2L full rate
    - **Packed RBC if transient response / no response
    - **    Consider early transfusion for transient / non-responder
    - Group O blood
    - FFP if coagulopathy
    - Platelet concentrates
    - Class 1 / 2 shock (<30% loss): Crystalloid, not much further intervention
    - Class 3 / 4 shock (>30% loss): Crystalloid + Blood, require further investigation with FAST / CT / Laparotomy
  2. Surgery
  3. Reassess frequently
17
Q

Fluid resuscitation

A

Large IV bore access:

  • ***x2 on each arm
  • ***Size >16
  • ***Warm IV fluid (Ringer’s lactate / Normal saline)
  • ***1-2L full rate
  • ***Packed RBC if transient response / no response

***Consider early transfusion for transient / non-responder:
- Dilutional effect of fluid resuscitation (crystalloid only improves volume but not O2 capacity) to blood O2 carrying capacity
- CO = HR X SV
—> SV depends on 1. Preload (IV volume) 2. Afterload (Peripheral resistance), 3. Contractility (possible cardiac failure in elderly / diseased heart)
(Rmb: CO cannot be increased if venous return does not increase)

Size matters:
- Maximum flow rate (ml/min)
—> 14G (brown): crystalloid (125), colloid (90)
—> 16G (grey): crystalloid (85), colloid (65)
—> 18G: crystalloid (60), colloid (35)

Crystalloid vs Colloid:

  • t1/2 of crystalloid (balanced salt solution BSS): ~20 mins
  • t1/2 of colloid (e.g. Gelofusin): ~4-6 hours
  • NO evidence to support superiority of colloid over crystalloid —> crystalloid reduce risk of fluid overload (colloid: may induce ***hypersensivity (gelatin), impair clotting (starch))
  • trauma leads to leaky cells in pulmonary capillary bed —> greater risk of ***pulmonary edema with colloid
18
Q

Blood transfusion

A
  • No level 1 evidence to define threshold for transfusion
  • Transient / Non-responder: Blood transfusion indicated
    —> when infusion of BSS >30 ml/kg —> transfusion indicated
    —> ratio of RBC:FFP:Plt = 1:1:1
  • ***NO steroid, vasopressor to treat hypovolaemic shock in trauma patients
  • Surgical intervention: stop the bleeding!!!
Complications:
1. Storage defect in blood product
- 2,3 DPG degradation: ↓ O2 affinity
- HyperK (40-70 mmol/L)
- Coagulation abnormality: Factor 5 / 8 decline quickly for 24 hours after collection
- Haemostatic failure
—> Hypothermia
—> Acidosis (citrate + lactate)
  1. Blood transmitted infections:
    - HBV / HCV
    - HIV
    - CMV
    - Malaria
  2. Haemolytic transfusion reactions
  3. Immunosuppression
    - ↑ ratio of suppressor to helper T cell —> infection
  4. Massive blood transfusion protocols
    - whole blood / packed cells / platelets / FFP
19
Q

Resuscitation: Disability

A
  1. Baseline neurologic evaluation
    - Pupillary response
    - GCS score
    - Neurosurgical consult as indicated
  2. Observe for neurologic deterioration
  3. ICP can rise rapidly past threshold of compensation —> Hernia
20
Q

Resuscitation: Exposure

A
  1. Completely undress patient
  2. Remove helmet if present
  3. Look for visible / palpable injuries
  4. Log-roll, protect spine
  5. Prevent hypothermia
21
Q

Resuscitation: Summary

A
  1. If in doubt, establish definitive airway (cricothyroidotomy if needed)
  2. O2 for all trauma patients
  3. Chest tube may be definitive for chest injury
  4. Stop the bleeding
  5. 2 Large caliber IV
  6. Prevent hypothermia
22
Q

Special considerations in Children

A
  • Trauma: leading cause of death
  • Immature anatomic / mechanical features
    1. Airway
  • larynx anterior + cephalad
  • short tracheal length
  1. Breathing
    - chest wall pliability
    - mediastinal mobility
  2. Circulation
    - vascular access (may need ***Intraosseous access), fluid volume, vital signs, urinary output
  3. Neurologic
    - vomiting, seizures, diffuse brain injury (***hypotension is enemy of neurosurgery)
  4. Musculoskeletal
    - immature skeleton
    - different fracture patterns
  • Vigorous physiologic response
  • Limited physiologic reserve
  • Size, dosage, equipment, surface area, psychology
  • Outcome depends on early, aggressive care
23
Q

Special considerations in Pregnancy

A
  • Anatomic / Physiologic changes modify response to injury
    1. Viscera
  • pushed upward
  1. Circulation
    - relative hypervolaemic state
    - physiologic anaemia
    - supine hypotension (∵ pressure on IVC)
  2. Breathing:
    - ↓ gastric emptying —> risk of aspiration
    - hyperventilatory state —>↓ PCO2
  3. Resuscitation
    - IVC compressed by fetus —> limit venous return to heart
  4. Gestation and position of uterus
  5. Isoimmunisation
    - may need to give Anti-RhD to Rh -ve mothers during blood transfusion
  6. Sensivity of fetus
    - see if need delivery
  • Need for fetal assessment
  • 1st Priority: Maternal resuscitation (best way to resuscitate baby is to resuscitate the mum)
  • Rupture amniotic membrane —> inevitably need to deliver baby (dead / alive)
  • Outcome depends on early, aggressive care
24
Q

Special considerations in Elderly

A
  • Injury: 5th leading cause of death
  1. Diminished physiologic reserve / response
    - Cannot mount compensatory response effectively e.g. tachycardia, vasoconstriction
  2. Comorbidities: Diseases
    - Co-existing HT —> mask underlying haemorrhage (normal BP may already signify shock)
  3. Medications
    - Aspirin, Anticoagulants —> coagulopathy
    - β-blockers: mask tachycardic response
  • Outcome depends on early, aggressive care

Cardiovascular:

  • Diminished pump function + lower CO
  • Inability to mount appropriate response to intrinsic / extrinsic catecholamines
  • Reduced flow to vital organs
  • Co-existing medication blunting normal physiologic response

Respiratory:

  • Decreased lung elasticity + pulmonary compliance
  • Atrophy of bronchial epithelium leading to decreased clearance of particulate foreign matter

Renal:

  • Decrease in renal mass
  • Increased vulnerability to nephrotoxic agents

Musculoskeletal:

  • Osteoporosis with inclination to fractures
  • Decrease in muscle mass

Comorbidities:
- DM / Liver disease / Malignancy / Neurological / Spinal disease

25
Q

***Secondary survey

A 
- Start after
—> Primary survey completed (i.e. patient stabilised / improved)
—> Resuscitation in process
—> ABCDE reassessed
—> Vital functions returning to normal
  1. ***Head to toe examination
    - Undressing + log-roll
  • Head
    —> complete neurologic exam
    —> GCS score determination
    —> comprehensive eye / ear exam (pupillary response, otoscopic exam, visual acuity)
    —> caution: unconscious patient, periorbital edema, occluded auditory canal
- Maxillofacial
—> bony crepitus / instability
—> palpable deformity
—> comprehensive oral / dental exam
—> caution: potential airway obstruction, cribriform plate fracture, frequently missed injury
- C-spine
—> palpate for tenderness
—> complete motor / sensory exams
—> reflexes
—> C-spine imaging (preferably CT scan)
—> caution: injury above clavicles, altered LOC, other severe / painful injury
- Neck
—> blunt vs penetrating
—> airway obstruction, hoarseness
—> crepitus, haematoma, stridor, bruit
—> caution: delayed S/S, progressive airway obstruction, occult injuries
- Chest
—> inspect, auscultate, palpate, percuss
—> re-evaluate frequently
—> CXR
—> caution: missed injury, ↑ chest tube drainage
- Abdomen
—> inspect, auscultate, palpate, percuss
—> re-evaluate frequently
—> FAST, DPL, CT
—> caution: hollow viscus and retroperitoneal injuries (not apparent on FAST scan), excessive pelvic manipulation (may disrupt haematoma —> further bleeding)
- Perineum
—> contusions
—> haematoma, ecchymosis
—> lacerations
—> urethral blood
- Rectum
—> blood
—> sphincter tone
—> high-riding prostate
—> pelvic fracture
—> rectal wall integrity
  • Vagina
    —> blood, lacerations
    —> caution: pregnancy (amniotic fluid leaking)
- Musculoskeletal
—> potential blood loss
—> limb / life threat (Primary survey)
—> missed fractures
—> soft tissue / ligamentous injury
—> occult compartment syndrome (esp. with altered LOC / hypotension)
—> examine patient’s back
—> splint long bones, analgesia
- Pelvis
—> pelvic fracture (major source of haemorrhage —> volume resuscitation, reduce pelvic volume, external fixator, angiography / embolisation)
—> pain on palpation
—> symphysis width ↑
—> leg length discrepancy
—> instability
—> pelvic X-ray
- CNS
—> frequent re-evaluation
—> prevent secondary brain injury
—> imaging as indicated
—> early neurosurgical consultation
- Spine
—> stepping / local tenderness
—> complete motor + sensory exam
—> imaging as indicated
—> maintain in-line immobilisation
—> early neurosurgical consultation
—> caution: incomplete immobilisation, subtle ↑ in ICP with manipulation, rapid deterioration
  1. Adjuncts
    - Blood tests
    - Urinalysis
    - X-ray
    - CT
    - Urography
    - Angiography
    - USG / Echo
    - Bronchoscopy
    - Esophagoscopy
    —> do NOT delay transfer
  2. ***AMPLE history
    - Allergy
    - Medication (Antiplatelet, Anticoagulant, β-blockers, Anti-HT)
    - Past medical history / Pregnancy
    - Last meal
    - Events / Environment
  3. Complete neurologic examination
  4. Special diagnostic tests
    - Skeletal survey (e.g. femoral X-ray, skull X-ray)
  5. Re-evaluation
    - Vital signs
    - Interventions (e.g. chest tube still in place?)
    - Missed injury
    —> high index of suscipion
    —> frequent re-evaluation
    —> continuous monitoring
    —> rapidly recognise patient deterioration
26
Q

Preparation for operation

A
  1. Inform anaesthetist + OT staff
  2. Initiate massive transfusion protocol
    - replacement of 100% of patient’s blood volume <24 hours
    - administration of 50% of patient’s blood volume in 1 hour
  3. +/- Arrange post-op ICU care
  4. Maintain reasonable BP before operation —> maintain adequate cerebral perfusion but not too high BP —> ***normotension before definitive measures may cause more bleeding
    - SBP ~90
    - MAP ~70
  5. Warm operating theatre
  6. Prepare fluid warmer, suction
  7. Prepare cell saver (i.e. Scavenge the lost blood —> for autotransfusion)
27
Q

***Operative management

A
  1. Generous midline laparotomy incision
    - from xiphisternum to pubic symphysis
  2. 4 quadrants packing
    - RUQ + LUQ + R iliac fossa + L iliac fossa
  3. Scoop out all blood clots
  4. Allow anaesthetist to administer blood products + clotting factors
  5. Remove packs from least bleeding site first (one by one)
    - Locate the bleeding site
  6. Definitive surgery (if stable) / Damage control surgery (DCS)
    DCS:
    - Stop bleeding
    - Control contamination: staple off injured bowel ***without anastomosis
    - Temporary abdominal closure: limit heat / fluid loss + protect bowels
    - After DCS —> Correction of acid/base balance, clotting, body temp —> Allow more time in definitive surgery since physiology is optimised —> Definitive surgery in 24-48 hours
28
Q

Pattern of injury

A

Depends on:

  1. Anatomy
  2. Physiology
  3. Mechanism of injury
29
Q

Burn injury

A
  1. Inhalation injury: Intubate, 100% O2
  2. Chemical burns: Brush + irrigate (large amount)
  3. Administer ***2-4 mL/kg/% BSA burn in 24 hours (+ Maintenance in children) —> Parkland formula
  4. Monitor urine output
  5. Expose + prevent hypothermia
  6. Antibiotic + Tetanus prophylaxis

Measurement:

  • Palm + Fingers = 1% BSA
  • Rule of 9
  • BSA: ***only for >=2nd degree burn (NOT for 1st degree burn)
30
Q

Cold injury

A

Frost bite:

  • Rewarm with moist heat (40oC)
  • Wait for demarcation

Hypothermia:
- Passive / Active rewarming

Monitor:
- Not dead until warm and dead

31
Q

Pain management

A
  • Relieve pain + anxiety as appropriate
  • Fast acting, IV opioid
  • Careful patient monitoring is essential (SaO2, BP, End-tidal CO2, RR, HR)
32
Q

Safe transfer

A

When patient’s needs > institutional resources

  • think about it during Primary survey
  • use time before transfer for resuscitation
  • do NOT delay transfer for diagnostic tests
  • physician-to-physician communication

Transfer to:

  • Trauma centre
  • Specialty centre
33
Q

Emergency preparedness

A
  • Simple plan
  • Command structure
  • Disaster triage scheme
  • Traffic control system

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