If there is potential that the patient’s airway may deteriorate then intubation prior to retrieval should be discussed with the ARV coordinator.
Always have emergency airway equipment available.
Limb fractures - closed:
Preventing hypothermia is a vital aspect of trauma care. It is important to maintain normothermia.
Ensure the patient does not lose excess heat due to exposure or wounds. Ensure all wounds are covered.
Administer warmed IV fluids; cover the patient with extra warm blankets as well as keeping the room warm (a general guide is that if clinical staff are comfortable it’s likely to be too cold for a trauma patient).
If available, the use of a forced air-warming machine is encouraged18. Ensure wound care is attended to prior to commencement. Avoid moist dressings when using a forced air-warming machine due to evaporative cooling effects.
Re-assess the patient and room temperature at regular intervals while awaiting the retrieval team.
A urinary catheter should be inserted and urine output measured hourly. The desired urine output for adults is 0.5–1.0 mL/kg/hr. Consider utilising a leg bag for urine containment as this is easier to package and reduces the risk of pressure area development.
A urinalysis should be performed also to check for blood. Discoloured, brown urine may indicate myoglobinuria, a sign of rhabdomyolysis.
Continuously monitor the heart rate, respiration rate, blood pressure, oxygen saturation and ETCO2 at 15-minute intervals or more frequently if indicated. Utilise electronic monitoring if available. All monitoring should be continued and documented until the retrieval team arrives. A baseline ECG should be taken prior to transfer if time permits and facilities exist.
A focused neurological assessment using the Glasgow Coma Scale should be performed. This should include a description of the patient’s level of consciousness as well as assessments of pupillary size and reactivity, gross motor function and sensation. Document the findings and reassess at frequent intervals.
|Best response||Eye opening||Verbal response||Motor response|
|1||Does not open eyes||Makes no sounds||Makes no movements|
|2||Opens eyes in response to painful stimuli||Incomprehensible sounds||Extension to painful stimuli (decerebrate response)|
|3||Opens eyes in response to voice||Utters inappropriate words||Abnormal flexion to painful stimuli (decorticate response)|
|4||Opens eyes spontaneously||Confused, disoriented||Flexion or withdrawal to painful stimuli|
|5||N/A||Oriented, converses normally||Localises painful stimuli|
Pathology tests should be taken for FBE (full blood examination), UEC (urea, electrolytes and creatinine) and glucose. Bedside/point-of-care testing is useful.
Serial blood gas assessment of pH and lactate levels provides good monitoring of tissue oxygenation, circulatory status and response to resuscitation.
Coagulation studies and group and cross-match should be taken if there is a high index of suspicion for major injuries requiring further care. Isolated results from single blood tests may be misleading and results should be considered in the context of the whole patient and trended results where available.
All patients should be kept nil orally in the initial post-resuscitation phase of injury.
The potential for a base of skull fracture in poly-trauma should be considered as a relative contraindication in the decision to insert an NGT. An OGT may be inserted following consultation and under direct visualisation.
Tetanus immunisation should be updated in the case of significant or contaminated wounds. Tetanus immunoglobulin should be given to patients who have not received a complete primary immunisation.19
Routine IV antibiotic administration is not recommended in major trauma, however, is indicated in open fractures (see limb fractures above).