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Clinical decision making tool for:
Traumatic peri-arrest OR
Traumatic cardiac arrest

Objective
The clinical decision making tool (see: Quick Chart) for traumatic peri-arrest / traumatic cardiac arrest aids on-scene times and provides guidance to manage patients to an extent that allows for rapid transport to a tertiary facility. Rapid transport of traumatic cardiac arrest or peri-arrest patients to definitive care whereby bloods, surgery and trauma surgeons are available allows for a higher and improved recovery rate.
Procedure
The skills indicated in the clinical decision making tool are limited but prove to be rapid and effective. Using the timeline to establish which skill has to be performed within that proposed time will assist with on scene times of less than 10 minutes. Failure to perform the skill should not prolong scene times, i.e.: failure to secure an IV within the allocated 5 minute mark should not delay extrication.
Patient Factors & Considerations
Cardiac arrest caused by catastrophic haemorrhage or of trauma related aetiology is seldom rectified in the pre-hospital environment. Key interventions are surgical in nature and or the administration of blood products, neither of which are available pre-hospital. The best possible outcome for these patients is rapid transport to these facilities. In accordance with the trauma services plan developed by the Department of Health, patients suffering major trauma should be taken to hospitals designated as Major Trauma Centres. Within the plan Royal Perth Hospital (RPH) is designated the State Major Adult Trauma centre and Perth Children's Hospital (PCH) the State Major Paediatric Trauma centre. Sir Charles Gairdner (SCGH) and Fiona Stanley Hospital (FSH) are designated metropolitan trauma services. Hospital notification ideally occurs once the decision is made that the patient will be transported under priority conditions. Consider State Trauma Unit (STU) if within 20 minutes from Royal Perth Hospital (RPH) on priority driving conditions.
Major Trauma Guideline

Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, including but not limited to blunt and penetrating injuries, falls, motor vehicle collisions, and gunshot wounds. Depending on the severity of injury, quick management and transport to the appropriate Trauma Centre may be necessary to prevent loss of life or limb. The following should be followed in regards to patients with suspected major trauma:

Adult:

  1. All patients with major trauma should be taken directly to RPH where possible.
  2. Where the patient’s condition appears imminently life threatening, diversion to the nearest appropriate emergency department for stabilisation should be undertaken.
  3. Trauma patients with obvious spinal injuries, who are pregnant or have major pelvic injuries, should always be taken to RPH except in imminent life threatening situations where stabilisation is required prior to transfer to RPH.
  4. Burns: Patients should be taken to FSH where possible. Should significant major trauma also be present, they should be taken to RPH.
  5. All country hospital transfers of major adult trauma should be taken to RPH. RFDS transfers will have a designated receiving hospital and crews should follow this.

Paediatric:

  1. All major paediatric (patients age less than 14 years) trauma (including burns) should be taken to PCH unless urgent stabilisation is required at the nearest appropriate emergency department prior to transfer to PCH.

Patients not suffering major trauma as defined in this guideline are to be transported to the hospital designated by the Ambulance Network Coordinator (ANC). Should the patient need specialised care as defined by the Clinical Services Matrix (Connect > Clinical Services > Clinical Services Matrix), the ANC should be contacted to inform them of the change of destination.

Major Trauma Criteria

In accordance with the trauma services plan developed by the Department of Health, patients suffering major trauma should be taken to hospitals designated as Major Trauma Centres. Major Trauma should be considered in any one of the following criteria:

Mechanism

  • MBA > 30 km/h with injuries.
  • MVA > 60 km/h with injuries.
  • Ejection from vehicle
  • Penetrating injury to head, neck, torso or proximal extremities.
  • Fall > 3m
  • Fatality on scene whereby the patient was in the same vehicle.
  • Pedestrian or cyclist with speed impact > 25km/h

Anatomical Criteria

  • Flail chest
  • Pelvic Fractures
  • Amputation / crush Injury proximal to hand and foot.
  • 2 or more long bone fractures
  • Suspected Spinal Injury
  • Polytrauma
  • Open or depressed skull fracture
  • De-gloving or mangled extremity proximal to hand and foot.

References

Director of Trauma Services Royal Perth Hospital / State Director of Trauma (WA).

European Resuscitation Council Guidelines for Resuscitation 2015, Section 4. Cardiac arrest in special circumstances.

Luna GK, Pavlin EG, Kirkman T, Copass MK, Rice CL. Hemodynamic effects of external cardiac massage in trauma shock. J Trauma 1989;29:1430–3.170.

Willis CD, Cameron PA, Bernard SA, Fitzgerald M. Cardiopulmonary resuscitation after traumatic cardiac arrest is not always futile. Injury 2006;37:448–54.171.

Lockey D, Crewdson K, Davies G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med 2006;48:240–4.172.

Crewdson K, Lockey D, Davies G. Outcome from paediatric cardiac arrest associated with trauma. Resuscitation 2007;75:29–34.

Key Terms & Links

Document Control


Directorate
Clinical Services

Responsible Manager
Head of Clinical Services

Date

Review Date

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