Clinical Update: Major Trauma patients with acute ECG changes – guidance on triage

Clinical Update

Major Trauma patients with acute ECG changes – guidance on triage

Major trauma patients are complex to manage and often present us with complex logistic decisions regarding triage to the most appropriate hospital. As you are all aware, we have a trauma triage tool (TTT) to guide decision making in the East of England, whether that be to the local trauma unit or major trauma centre at Addenbrookes. The Trust also has the critical care desk (CCD) to assist with these decisions (accessible 24/7 on CH202). We have been asked to provide some guidance to you all regarding a very small cohort of major trauma patients who also present with acute ST elevation – thus creating further complexity to appropriate triage, essentially deciding whether the patient should be prioritised for major trauma or PPCI pathways.

There are a range of reasons why trauma patients may also have ST elevation on ECG. This may be the cause of the injury event or the consequence – it can be very difficult to differentiate. The regional Trauma Network policy is that all triage positive trauma patients are managed via the major trauma pathway – PPCI can be reviewed as necessary once the patient has arrived at the TU/MTC. Therefore, if you attend a patient who has sustained significant trauma and meets any of the anatomical or physiological criterion set out in the TTT, who is subsequently found to also have ST elevation, please treat them as a major trauma candidate and take them to the most appropriate destination (TU/MTC) based on the decision process on the TTT.

We should notify CCD about all major trauma candidates, seeking additional HEMS/BASICS support to scene where appropriate, also stating the triage tool status of the patient based on your assessment.  The CCD clinician will be able to advise the most appropriate hospital destination, as well as arrange dispatch of any additional support that may be required to scene. The CCD clinician can also speak to the Network Coordination Consultant (NCS) for additional advice where necessary.

Clearly, we quite often attend patients who suffer out-of-hospital cardiac arrest, sustaining soft tissue injuries as they collapse. These should continue to be treated medically and would still follow the PPCI pathway – the above relates to patients who have undergone significant trauma only.

 

A recent example might bring this to life:

40yo male chest pain and cardiac arrest whilst driving, crashed into a tree, airbags deployed.

STEMI on ECG after ROSC. Intubated pre-hospital by medical team. Split team opinion regarding optimal triage: direct to PPCI (minimal external evidence of injury) or MTC first.

Discussion with PPCI cons, who eventually offered option of CT at PPCI centre which wasn't MTC or TU. Conveyed to PPCI centre, echo by PPCI cons, pan-CT identified liver laceration - did not proceed to PPCI. Medical team stayed to support and transfer patient on to MTC.

Admitted to trauma intensive care at MTC. Cleared for antiplatelet and PCI by hepatobiliary surgeons after review. Transfer for PPCI (3 stents to RCA) the following day and then returned to MTC.

If you have any queries regarding the above, please contact rob.riches@eastamb.nhs.uk

 

This clinical update can be downloaded as a PDF using the link below.

Published 11th September 2020

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