The Changing Face of Major Trauma in the UK

Transcription

1 The Changing Face of Major Trauma in the UK Emergency Medicine Journal 2015 Trauma Audit Research Network (TARN) database Review 1990 to end 2013 n=116,467 Data interrogation: Age Gender Mechanism of injury Use of CT Kehoe A et al Emerg Med J 2015;32:911-15

2 Results ISS>15 Mean age 1990 = 36.1 years 2013 = 53.8 years Group Size (age) 1990 = under 25 years (39.3%) 1990 = over 75 years (8.1%) 2013 = under 25 years (17%) Males 2013 = over 75 years (26.9%) 1990 = 72.7% 2013 = 65.3% CT Scans 1990 = 33.6% 2013 = 86.8% Kehoe A et al Emerg Med J 2015;32:911-15

3 Mechanism of Injury 1990 RTC (59.1%) Falls greater than 2 metres (18.6%) Falls less than 2 metres (4.7%) Shootings and stabbings (0.2%) Others (17.4%) 2013? Kehoe A et al Emerg Med J 2015;32:911-15

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5 Fall <2m as Mechanism of Injury % 2 15% 3 25% 4 40% 5 50% Kehoe A et al Emerg Med J 2015;32:911-15

6 Who to worry about?

7 Stealth trauma Designed (by technology) to make detection (by radar) difficult Significant (major) trauma sustained after falling from standing i.e. low impact mechanism

8 Progress who s involved Clinical Reference Group for Major Trauma and Burns Recognizing: Frailty Futility Different care pathways Balancing needs of patient and carers Complexity of triage Perception: Not de-stabilising newly established pathways Do not want 2 tier system Do not want to over treat Matthew Wyse QE Hospital Elderly Trauma Lecture

9 CRG-Principles The majority can be managed in their local Trauma Unit. Major Trauma Centres and Operational Delivery Networks should support the care Trauma Units Elderly trauma patients requiring higher level of care should be rapidly transferred to Major Trauma Centres Care of the Elderly clinicians should have shared responsibility for the management of elderly major trauma patients Elderly trauma patients should have the same standard of care as non- elderly major trauma patients The major trauma network should be actively engaged in the falls prevention strategy Matthew Wyse QE Hospital Elderly Trauma Lecture

10 CRG-Commissioning standards MTCs: All elderly major trauma patients should be admitted under joint care of a trauma service and elderly care team. They should be assessed by care of the elderly teams within 72 hours of admission TUs: All elderly trauma patients should be admitted under care of the elderly teams, with active input from relevant surgical specialties Elderly trauma patients should have a frailty assessment / comprehensive geriatric assessment commenced within 72 hours The management and outcomes of elderly major trauma patients should be regularly audited by the Major Trauma Network Matthew Wyse QE Hospital Elderly Trauma Lecture

11 Progress who s involved Clinical Reference Group for Major Trauma and Burns PanLondon Elderly Trauma Group Northumbria s Elderly Trauma Campaign

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13 Progress who s involved Clinical Reference Group for Major Trauma and Burns PanLondon Elderly Trauma Group Northumbria s Elderly Trauma Campaign Heartlands Elderly Care Trauma and Ongoing Recovery

14 HECTOR The Heartlands Elderly Care Trauma & Ongoing Recovery Programme The ethos of the course is to attempt to ensure that patients of advancing age receive safe and high quality trauma care. This care should focus on them as individuals and be directed towards treating the patient with injuries, not injuries on a patient.

15 Progress who s involved Clinical Reference Group for Major Trauma and Burns PanLondon Elderly Trauma Group Northumbria s Elderly Trauma Campaign Heartlands Elderly Care Trauma and Ongoing Recovery Regional Elderly Trauma Group for NTN

16 Regional Elderly Trauma Group Set up by NTN August 2016 Networkwide forum for development of strategy & pathway of care for the management of major trauma in the elderly. Including prehospital & in-hospital identification, & the ongoing treatment & rehabilitation of this cohort of patients.

17 Scenario 1 85 year old lady, been a bit wobbly lately and has macular degeneration. Fell in sitting room and hit left side of chest on chair Mildly impaired mobility recently under GP review, registered blind due to macular degeneration Sitting in wheel chair in waiting room complaining of left sided chest pain, not too bad, 4 or 5/10 Observations all within normal limits, sats 98% on air, good air entry throughout chest ECG SR nil acute

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19 Scenario 1 1 Analgesia & CI advice 2 - Physio/OT assessment 3 CXR 4 CT thorax 5 PAN scan

20 CT report - Fractures of left 4 th, 5 th, 6 th and 7 th ribs. Small left sided haemothorax, minor basal contusion and very small left apical pneumothorax.

21 Scenario 1- Issues Where to admit? Correct level of analgesia Risk of delirium, need for baseline screen Other risks constipation, AKI, PNEUMONIA Why fell? Further down the line DNAR and TEP? Deconditioning, risk that won t get back to baseline

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23 Scenario 2 83 year old lady with dementia in a nursing home, brought in by carers after a witnessed fall Report her normal level of cognitive function but complained of neck pain at triage On examination no c spine tenderness, moving all 4 limbs normally.

24 Scenario Home with HIWA 2 Physio/OT assessment 3 CT head 4 c-spine x-ray 5 CT c-spine 6 CT head & c-spine

25 Scenario 2 Returned 2 further times over the next 3 days Developed delirium on top of dementia Treated for presumed UTI Third attendance had CT head & c-spine Fractured C2 involving both sides of the vertebra as well as possibly right foramen transversarium, therefore an unstable fracture

26 ELDERLY TRAUMA IN THE FRAIL Whole system change MDT approach avoid the chaos! Join in, help make the change

27 @v_lottie