Comprehensive Study Notes: NBMH2624 Emergency and Trauma Care

Foundations of the Trauma Care System and Emergency Department Operations

A trauma care system is a healthcare delivery system that integrates and coordinates emergency medical services (EMS) or prehospital care with hospital resources to provide optimal care for patients. Its primary development goal is to minimize the time between an injury and definitive care management. This system represents a continuum of integrated care, involving coordinated efforts between out-of-hospital providers on-site and in-hospital medical specialists. The Trauma Care Systems Planning and Development Act 1990 led to the Model Trauma Care System Plan established in 1992, which serves as a critical link encompassing phases from resuscitation to rehabilitation. This is often referred to as the trauma chain of survival, requiring that patients be transported to facilities with appropriate resources in a safe, efficient, and cost-effective manner. Figure 1.3 in the manual illustrates emergency care practitioners at work in these complex environments.

Emergency care practitioners treat individuals of all ages with perceived or actual physical or emotional health alterations. The emergency department (ED) is unique because it operates 24 hours a day, seven days a week, and can shift from quiet to hectic almost instantly. Patient conditions in the ED depend on external factors such as weather, road accidents, industrial mishaps, and fires. Practitioners handle urgent situations where the cause of illness or injury may still be unknown and must coordinate with doctors, family members, and various specialists. The three major components of emergency care practice are the setting (hospitals, prehospital areas, air/ground transport, military areas, urgent care clinics), the environment (unplanned situations, limited resources, unpredictable patient numbers, cultural variables), and Standard Operating Procedures (SOPs), which include criterion-based job descriptions, policies, and research projects.

The Three Phases of Trauma Care and the Golden Hour

Trauma care is categorized into three distinct phases. The first is the Pre-incident phase, where the primary role of the practitioner is public education regarding the use of personal restraint systems and self-injury prevention. The second is the Incident phase, which focuses on the prevention of intentional and unintentional trauma through education or law reinforcement. Examples include the use of active systems like seat belts and passive systems like airbags to reduce mortality and morbidity, along with health campaigns. The third is the Post-incident phase, where practitioners use expertise to deliver care. Their responsibilities include performing life-saving manoeuvres, conducting definitive care and procedures, preparing patients for transportation, and moving patients to the appropriate medical facility.

The first hour following an emergency or severe injury is known as the "golden hour." This is a critical period where medical and surgical interventions can significantly enhance survival chances and reduce complications. Healthcare providers must identify patients in this critical window and ensure that prehospital care does not delay transport to a facility capable of providing definitive care through rapid assessment and stabilization.

Ethical and Medico-legal Considerations in Emergency Care

Ethics in the healthcare profession provide a written code guiding members through difficult decisions, representing a model of ideal conduct. The code of ethics for emergency practitioners includes collaborating with multidisciplinary teams, acting with compassion and integrity, maintaining accountability, and protecting individuals from incompetent or illegal practices. Practitioners must respect patient privacy and confidentiality, advocate for public health access, and participate in research to close knowledge gaps. Patient care details must remain strictly confidential unless the patient is a minor or legally incompetent.

Legal responsibilities rise in tandem with professional practice. Practitioner licenses or annual practicing certificates (APC) certify they are qualified by law to practice and provide holistic care. Five elements are required to prove medical negligence: Duty to Act (forming a relationship to assume care), Breach of Duty (commission or omission falling below standards), Cause in Fact (the injury resulted from the practitioner's conduct), Proximate Cause (the injury was a foreseeable result), and Damages (compensation for care, wages, or suffering). Professional negligence specifically requires a duty to act, conduct below the standard of care, an actual injury, and that the conduct was the direct cause of the injury. Classification of laws include Tort Law (breach of legal duty), Do Not Resuscitate (DNR) orders, and various degrees of negligence from Ordinary (omissions during care) to Gross (wilful and reckless conduct causing injury).

Patient Consent and Documentation Standards

Consent is essential to uphold patient autonomy and provide a legal defense. There are four primary types of consent. Consent is the general agreement from a mentally competent adult to accept or refuse care. Informed Consent requires the patient to have a full understanding of risks and benefits while not under the influence of substances. Expressed Consent is verbal or written permission for examination or transport, which can be withdrawn at any time. Implied Consent allows for treatment in emergencies when the patient is unresponsive or unable to respond. Key points include assuming adult capacity unless proven otherwise and understanding that practitioners may be liable if procedures are performed without valid consent.

Communication and documentation are fundamental to quality care in chaotic settings. There are five types of communication: Base Station Radios (fixed locations, power $100\,W$ or more), Mobile and Portable Radios (installed in ambulances, range $10\,km$ to $25\,km$; handheld at $1\,W$ to $5\,W$), Repeater-based Systems (retransmitting radio messages), Digital Equipment (using telemetry to send coded signals like ECGs), and Cellular Telephones. Mandatory written communication includes the Minimum Data Set: patient information, chief complaint, mental status, systolic BP for patients over $3\text{ years}$ old, capillary refill for those under $6\text{ years}$ old, skin color/temperature, pulse, respiration, and detailed incident times (notified, arrived, departed, transferred). Reporting errors like false statements must be avoided, and specific situations like gunshot wounds, animal bites, and suspected abuse require special reporting.

Age-Related and General Patient Assessment in Emergencies

Emergency care must vary based on age-specific needs across four categories: neonatal/infant, child/adolescent, adult, and geriatric. Regardless of age, the practitioner must address safety, privacy, comfort, and involvement of family. Approaches to physical assessment, medication administration, and communication style must be tailored to the complexity of the patient's age group. Patient assessment is a systematic method of evaluating physical conditions through inspection, auscultation, palpation, and percussion.

The assessment process includes several components: sizing up the scene for safety, identifying life-threatening conditions, performing physical assessments, obtaining vital signs, taking medical history, and preparing for transport. Scene size-up follows the mnemonic U-H-E-N-T-A-M: Universal Precautions, Hazard identification, Extra resources needed, Number of victims, Types of injury, Accessibility, and Means of injury. Personal Protective Equipment (PPE) like latex gloves, eye protection, masks, gowns, and safety boots are mandatory as all body fluids are considered infectious risks.

Initial Assessment and the AVPU Scale

Initial assessment involves developing a general impression of the patient and obtaining consent. Mental status is assessed using the AVPU mnemonic: Alert, Responsive to Verbal Stimulus, Responsive to Pain, or Unresponsive. Airway assessment involves checking for obstructions; medical cases use the head tilt-chin lift while trauma cases require the jaw-thrust. Breathing is assessed for adequacy by looking for accessory muscle use or nasal flaring. Circulation is evaluated by looking for bleeding, skin color, and capillary refill. Priority patients are those with breathing difficulty, severe pain, sign of poor perfusion, or uncontrolled bleeding.

Rapid Trauma Survey (RTS) or Focused History and Physical Examination (FHPE) decisions are based on the Mechanism of Injury (MOI). Generalized MOI (like a fall from height) requires an RTS, while localized MOI requires an FHPE. The mnemonic DCAP-BTLS is used to identify injuries: Deformities, Contusions, Abrasions, Punctures/Penetrations, Burns, Tenderness, Lacerations, and Swelling. A rapid physical examination should take only $60$ to $90\,seconds$ and includes checking the head, neck (apply cervical collar), chest, abdomen, pelvis, extremities, and posterior body.

Medical History, Physical Exams, and the Glasgow Coma Scale

Medical history is gathered using the SAMPLE mnemonic: Signs/symptoms, Allergies, Medications, Past pertinent history, Last oral intake, and Events leading to the incident. Detailed physical examinations are conducted systematically from the head down, including palpating the zygomas, maxillae, and mandible, looking for jugular venous distension (JVD), and auscultating lung sounds at the bases and apices.

Ongoing assessment is required every $5\,minutes$ for unstable patients to detect changes. This involves repeating initial assessments, reassessing vitals ($BP$, $Pulse$, $RR$, $SpO_{2}$, $Temp$, $ECG$), and checking intervention effectiveness (oxygen delivery, ventilation). The Glasgow Coma Scale (GCS) provides an objective score for consciousness based on eye-opening ($1$ to $4$ points), verbal response ($1$ to $5$ points), and motor response ($1$ to $6$ points). A GCS of $13/15$ indicates mild injury, $8$ to $12/15$ indicates moderate injury, less than $8/15$ indicates severe injury/unconsciousness, and a score of $3/15$ represents no response.

Triage Systems and Clinical Documentation

Triage is the process of sorting patients to ensure the right person gets to the right place at the right time. There are three-level and five-level systems. A three-level system includes Emergent (Red Zone; immediate intervention for life/limb threats), Urgent (Yellow Zone; delayed up to $30\,minutes$), and Non-urgent (Green Zone; wait more than $1\,hour$). Under-triage (treating severe injuries in non-trauma centers) is dangerous, while over-triage (minimal injuries in trauma centers) overburdens the system. Five-level systems include the Canadian Triage and Acuity Scale (CTAS) and the Emergency Severity Index (ESI).

Documentation of assessment and resuscitation is professional and medico-legal evidence. Modern systems use the Identify-Assessment-Action-Response-Recommendation framework. Progress notes must be recorded in real-time, detailing abnormal findings (tachycardia, desaturation), change in condition, adverse events, and patient outcomes after interventions. Professional language must be used, and generic statements like "ongoing" should be avoided.

Respiratory and Cardiovascular Emergencies

Normal breathing involves an intact airway, normal respiratory rate, and SpO_{2} > 94\%. Respiratory distress presents with restlessness, cyanosis, and accessory muscle use. Respiratory failure occurs when tidal volume is no longer adequate, and respiratory arrest is the cessation of breathing. Management includes establishing an airway and providing positive pressure ventilation at $10$ to $12\,breaths/min$ for adults and $12$ to $20\,breaths/min$ for children. Beta 2-agonist drugs (salbutamol) may be administered via Metered-Dose Inhaler (MDI) after checking the "Eight Rights": Patient, Medication, Dose, Route, Time, Documentation, Reason, and Response.

Cardiovascular emergencies often involve chest pain, which can be sharp, dull, or crushing. Stable Angina is chest pain from ischemia relieved by rest or nitroglycerin within $3$ to $5\,minutes$. Acute Coronary Syndrome (ACS) ranges from unstable angina to Acute Myocardial Infarction (AMI). AMI occurs when coronary arteries are blocked, leading to tissue death; it is not relieved by rest. Congestive Heart Failure (CHF) involves inadequate pumping, where left-sided failure causes fluid in the lungs (pulmonary edema) and right-sided failure causes swelling in the extremities. Cardiogenic shock occurs when $40\%$ of the left ventricle is damaged. Emergency care for cardiac patients involves high-flow oxygen at $15\,L/min$ and potentially aspirin or nitroglycerin if systolic BP > 100\,mmHg.

Neurologic, Endocrine, and Genito-urinary Emergencies

Strokes are divided into ischemic (blood flow blockage) and haemorrhagic (vessel rupture). Symptoms include facial drooping, ataxia, and dysarthria. Seizures (convulsions) may be grand mal (generalized) or partial. A tonic-clonic seizure involves a tonic phase (rigidity) and clonic phase (jerking), followed by a postictal state ($5$ to $20\,minutes$). Altered Mental Status (AMS) is caused by hypoglycemia, hypoxia, or drug overdose. Endocrine emergencies like Hypoglycemia require oral glucose or IV dextrose (Adult: $1\,cc/kg$ of $D50$; Children: $2$ to $4\,cc/kg$ of $D25$). Diabetic Ketoacidosis (DKA) in Type 1 diabetics presents with Kussmaul respirations and fruity breath.

Genito-urinary injuries include kidney damage (indicated by flank hematoma) and urinary bladder rupture (linked to pelvic fractures). Male reproductive injuries can result from straddle falls or crushing. Female reproductive emergencies include obstetric crises: Antepartum haemorrhage (Placenta abruption or previa) and Post-partum haemorrhage (caused by uterine atony or retained fragments). PPH management involves uterine massage, IV oxytocin, and volume resuscitation.

Toxicological and Environmental Emergencies

Toxicological emergencies involve exposures through inhalation, ingestion, injection, or contact. Stages of care involve primary assessment (ABCD) and differential diagnosis like risk for poisoning or impaired gas exchange. Interventions include activated charcoal (though not for caustics, heavy metals, or lithium) and gastric lavage if ingested within $1\,hour$. Environmental emergencies are driven by homeostasis and thermoregulation. Heat Cramps involve sodium loss and muscle spasms. Heatstroke is life-threatening with a core temperature > 104^{\circ}F ($40^{\circ}C$). Hypothermia begins at less than $95^{\circ}F$ ($35^{\circ}C$); mild case ($93.2^{\circ}F$) requires passive rewarming, while severe cases ( < 86^{\circ}F) require active core rewarming.

Haematologic and Oncologic Emergencies

Haematology is the study of blood (plasma $55\%$, formed elements $45\%$). Sickle cell and haemophilia are common issues. Oncologic emergencies include sepsis (treat with antibiotics after culture), DIC (abnormal clot formation in microthrombi), SIADH (excess ADH causing fluid retention and hyponatremia; levels around $110\,mEq/L$), Spinal Cord Compression (tumor invasion), Hypercalcemia (tachycardia moving to bradycardia), Superior Vena Cava Syndrome (SVC; blockage causing Stokes sign), and Tumor Lysis Syndrome (TLS; release of potassium and uric acid causing renal failure).

Behavioural Emergencies and the SAFER Model

Behavioural emergencies are abnormal actions where harm is imminent, caused by trauma, medical issues (hypoglycemia), or psychiatric disorders. Assessment uses the AABCST model: Appearance, Affect, Behaviour, Cognition, Speech, and Thought Processes. The SAFER model for intervention stands for: Stabilize the situation, Assess and acknowledge the crisis, Facilitate understanding, Encourage resources/coping, and Recovery or Referral. Restraints, if used, must be soft and humane, with one person per extremity and one for the head, always in a supine position.

Trauma Emergencies: Shock, Soft Tissue, and Burns

Shock (hypoperfusion) is the failure of the circulatory system to provide oxygen to vital tissues. Types include Neurogenic (nerve paralysis), Cardiogenic (pump failure), Septic (toxins), Anaphylactic (allergic), and Hypovolemic (fluid loss). Stages are Compensated (agitation, clammy skin), Decompensated (BP < 90\,mmHg, ashen skin), and Irreversible (terminal). Management involves high-flow oxygen and potentially elevating legs $6$ to $12\,inches$ if no fractures exist.

Soft tissue injuries involve RICE treatment: Rest, Ice, Compression, and Elevation. Amputated parts should be wrapped in dry sterile gauze, placed in a plastic bag, and put on ice (not direct contact). Impaled objects should be stabilized in place, not removed. Burns are classified by depth: First degree (superficial epidermal), Second degree (partial thickness; blisters), Third degree (full thickness; leathery/dry), and Fourth degree (involves bone/muscle). The Rule of Nines estimates TBSA in multiples of $9\%$. Critical burns include any involving the airway, hands, feet, or more than $10\%$ full-thickness TBSA.

Cranio-facial, Neck, Chest, and Abdominal Trauma

Traumatic Brain Injury (TBI) mechanisms include acceleration, deceleration, and coup-countercoup. Signs of basal skull fracture include Raccoon eyes and Battle's sign. Interventions for neck injuries include occlusive dressings to prevent air embolism. Heart injuries like Pericardial Tamponade (blood in the pericardial sac) cause JVD and faint heart tones. Chest issues include Pneumothorax (air in pleural space), Tension Pneumothorax (tracheal deviation, distended neck veins), and Flail Chest ($3$ or more ribs broken in $2$ or more places). Abdominal trauma involves hollow organs (stomach, intestines) and solid organs (liver, spleen). Evisceration (protruding organs) requires moist sterile dressings; do not replace the organs.

Orthopaedic Emergencies and Splinting

Fractures are categorized as closed, open, non-displaced (hairline), or displaced. Specific types include Greenstick (incomplete), Comminuted (multiple fragments), and Pathologic (diseased bone). Compartment syndrome occurs with elevated pressure in the fibrous tissue, requiring fasciotomy within $4\,hours$. Splinting principles include immobilizing the joint above and below the injury and padding rigid splints. Types of splints include Hare traction (for femur fractures), vacuum splints, and air splints. In-line traction is the act of exerting a pulling force to realign a bone.

Disaster Relief Operations and PTSD

An MCI occurs when healthcare needs exceed resources. The Disaster Paradigm is D-I-S-A-S-T-E-R: Detection, IMS, Safety/Security, Assess Hazards, Support, Triage/Treatment, Evacuation, and Recovery. Triage categories are Minor (Green), Delayed (Yellow), Immediate (Red), and Deceased (Black). M.A.S.S. Triage stands for Move, Assess, Sort, Send.

Post-Traumatic Stress Disorder (PTSD) involves re-experiencing trauma through flashbacks or emotional numbness for at least $1\,month$. Treatment includes trauma-focused cognitive-behavioural therapy and medications like antidepressants or propranolol. EMDR (Eye Movement Desensitisation and Reprocessing) helps unfreeze information processing. Helping victims requires companionship, accepting their cues, and understanding PTSD triggers.

End of Life (EOL) and Pain Management Protocols

EOL care refers to support during a fatal condition. Hospitals use the "Two Roads to Death" model: the Usual Road (sleepy, lethargic) and the Difficult Road (restless, confused, hallucinations). Trajectories of illness include Sudden Death, Terminal Illness, Organ Failure, and Frailty. Prognostic signs of near-death include the "death rattle" (median survival $1\,day$) and mandibular movement (median survival $2.5\,hours$). DNR orders are increasingly called "Allow Natural Death" (AND).

Pain is assessed as the fifth vital sign using the Numeric Rating Scale ($0$ to $10$), Wong-Baker FACES, or the Colour Scale. Types of pain include Somatic (aching), Visceral (deep squeezing), and Neuropathic (burning/tingling). Medications include Paracetamol ($1\,g$ qds), NSAIDs (Ibuprofen, Naproxen, Diclofenac), and Opiates (Morphine $0.1-0.2\,mg/kg$ IV). Communicable diseases to monitor include TB (Mycobacterium tuberculosis), Cholera (Vibrio cholerae), Dengue (Aedes aegypti mosquito), Zika, and Hepatitis A, B, and C.