Category: Resus
Major Trauma Network
We are part of the West Yorkshire Major Trauma Network with our MTC at LGI
We know that from time-time patient are brought to us and we find injuries that are more appropriate to manage at the MTC. This is inevitable as the on scene triage tool is never going to identify every major trauma patient – this is a failing of the tool not the crew. The decision tree below can help you arrange transfers in the most timely and appropriate manner. Read more
CPAP Set-Up
NIPPV 3 machines are used throughout the trust to deliver NIV and CPAP – and should be commenced in ED if transfer to ward/ICU is adding significant delay
- NIV/CPAP is NOT an Aerosol Generating Proceedure (AGP) [as of Sept 2022]
- CPAP/EPAP levels of 8-15cmH2O
This video demonstrates how to set up CPAP on the NIPPV 3
Acute Behavioural Disturbance / Excited Delirium
Most of us will have seen patients like this – agitated, aggressive and often with police or security pinning them down.
- High risk of Cardiovascular Collapse/Death – likely due to adrenaline surge, heat exhaustion and injury. It can happen very suddenly.
- Keep physical restraint to a minimum – Don’t allow patient to forced face down, it’s the most likely way of killing them.
- Sedation – if you’re restraining you will almost certainly need to sedate. IV is best but if access is too risky IM will have to do.
- Aggressive management of underlying issues – esp. hyperthermia and acidosis and look out for rhabdomyolysis and DIC
Refusing treatment = Mental Capacity Assessment [LINK]
| Drug | Route | Typical Dose (mg) | Onset (min) | Duration (min) | Warning |
|---|---|---|---|---|---|
| Midazolam | IV | 2-5 | 1-5 | 30-60 | Respiratory depression, IM unpredictable onset |
| IM | 5 | 10-15 | 120-360 | ||
| Lorazepam | IV | 2-4 | 2-5 | 60-120 | |
| IM | 4 | 15-30 | 60-120 | ||
| Haloperidol | IV | 5-10 | 10 | 180-360 | Arrhythmia Risk: Only if previously used OR ECG |
| IM | 10-20 | 15-30 | 180-360 | ||
| Ketamine | IV | 1-2mg/kg | 1 | 20-30 | Theoretical risk of worsening cardiovascular instability |
| IM | 2-4mg/kg | 3-5 | 60-90 |
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Myocardial Infarction (MI) – PPCI/Thrombolysis
PPCI (Leeds PPCI Pathway)
- Target: Door to balloon 90min
- Criteria:
- Time: Chest pain within 12hrs (or worsened within 12hrs)
- ECG: ST elevation MI (1mm Limb or 2mm Chest leads) OR New LBBB. (Posterior MI do posterior leads and discuss with LGI)
- Actions:
- Resuscitate
- Contact PPCI team @ LGI (Mobile No. up in Resus)
- Arrange blue light (P1) ambulance to LGI
- Prasagrel 60mg if no previous CVA or Ticagrelor 180mg if previous CVA and Aspirin 300mg (if anti-coagulated Discuss with PCI team)
- Problems:
- Intubated patient: Often LGI would accept but need to arrange Cardiac ICU. If no bed patient could go for PCI to return locally immediately after PCI to our ICU’S?
- LGI Full: Occasionally the cath lab is full and can’t accept your patient
- Calling Manchester and Sheffield: It’s worth a go but they don’t have agreements with us so having your patient accepted can be difficult
- Don’t Forget Thrombolyisis: We need to open up the patients artery, if there is no quick decision to go for PPCI – Consider Thrombolysis
ECG placement & mis-LEADing ECG’s
- V1: 4th intercostal space (ICS), RIGHT margin of the sternum
- V2: 4th ICS along the LEFT margin of the sternum
- V4: 5th ICS, mid-clavicular line
- V3: midway between V2 and V4
- V5: 5th ICS, anterior axillary line (same level as V4)
- V7: Left posterior axillary line, in the same horizontal plane as V6.
- V8: Tip of the left scapula, in the same horizontal plane as V6.
- V9: Left paraspinal region, in the same horizontal plane as V6.
Paediatric – Time Critical Transfers (non-trauma)
Definition of a time critical transfer
Transfer of a patient for life, limb or organ saving treatment when the time taken to provide this treatment is a critical factor in outcome.
Principles
- Acceptance by the regional centre is NOT dependent on bed availability.
- Time critical transfer should normally be provided by the referring hospital team NOT Embrace.
Paediatric Ketamine Sedation
RCEM 2022 Safe sedation in the ED and RCEM Ketamine for paediatric procedural sedation guideline. Please read these documents in full or participate in RCEM learning for further information.
Adult Sedation
This guideline is a brief summary of the RCEM 2022 Safe sedation in the ED and RCEM – Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department – March 2019. Please read these documents in full or participate in RCEM learning elearning for further information. Read more
Emergency Tracheostomy/Laryngectomy Management
Occasionally patients with Tracheostomy or Laryngectomy present with difficulty breathing due to problem. As this is rare for us in ED, this situation can be very difficult for all of us. However the protocols below can help.
Tracheostomy
Tracheostomy is simply a passage from the neck into the trachea. In most cases the trachea will still be connected to the nose and mouth (so can breath though their mouth too).
