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Aide Memoire_6pp_DL 15/9/06 3:42 pm Page 1 Exposure and Fractures?
GCS < 8 or fluctuating – intubate or pO2 < 8 Kpa - intubate Ensure secondary survey has been completed (ATLS) Transfer course Aide Memoire
Suction, spare equipment for potential loss of airway, Fractures must be stabilised (bones grate against each other with the vibration of travel), and also imply blood loss/risk or History compatible with injury? Examination? Clearance Fluids, Electrolytes and Renal
depends upon definitive CT protocol, Scans reviewed by Sodium? Do NOT attempt complete or rapid correction unless If in doubt manage as if injured -> Neutral position, Collar +/- Potassium (aim 4.0 to 5.0). Correct to safe range BEFORE Breathing
Mg >1.0 (give 20 mmol if necessary, esp MI or PET) Correct acidosis. Bicarbonate BY INFUSION if required Ventilated – stabilise 15 minutes prior to transfer on transport Rib fractures or Pneumothorax= CHEST DRAIN
Nasogastric tube on free drainage - (Oral if base of skull Drains always unclamped (except post pneumonectomy)
Circulation
‘Full patients travel better’
Give fluids and assess CVP & perfusion prior to transfer Ensure MAP > 75mmHg (>90 mmHg in Neuro), Ensure NOT SUITABLE FOR TRANSFER unless purpose is Assessment of the patient
Haematology
Airway & Cervical spine
Ensure Hb > 7.0 or Aim > 10 if any risk of bleeding or recent Fluids – (volumetric pumps are not designed to travel) Breathing
If in doubt start low dose pressors and/or inotropes, Noradrenaline usually best if sedated, and augments benefit Circulation
What products have been given? Have you got and checked the cross-matched blood? Known antibodies? Disability (Neuro)
Make sure all infused drugs clear dead space: a 3 way tap has a dead space of (≈0.5ml) + lumen (0.3-0.5ml) ≈ 1ml, so at Infection
Exposure and Fractures
2 ml/h may take 1h. Run at 20ml/h for 2 mins then 10ml/h Does your hospital have any current problems with Fluids electrolytes and renal
multiresistant or transmissible organisms (e.g. MRSA, VRE, Disability (Neurological status)
Does this patient have any MR bug? Are they a contact? Any Haematology
other transmissible infection (esp TB, HIV, HBV, HCV) Clinical Examination (symmetry). Best GCS? Current GCS? Does the patient have active infection? Known bugs? What Infection
Response to pain centrally (V) and peripherally antibiotics? Doses up to date? Have appropriate Cultures Eye movements (II, III, IV, V, VI, VIII) Infusions
Organisational
Just in case (Mobile etc)
Sedation + Analgesia (Propofol + Opioid) Kit check
SEDATE ALWAYS if orally intubated, Relaxants USUALLY Always consider seizures a possibility (Nonconvulsive status). Lab Results
Monitoring
Raised ICP -> KEEP MAP > 90, Deeper sedation Exposure (and Fractures)
Notes & X rays
Put vasoactive drugs on smallest lumens = white or blue 18G Keep larger CVP lumens (grey 14G) for rapid infusion Paperwork and Phone
Remember mechanical backlash, and dead space – usually Wrap well with blankets (even if just going along corridors) Quality control
about 1ml before any drug reaches the patient Ready to …….
Aide Memoire_6pp_DL 15/9/06 3:42 pm Page 2 Just in case
Ready to Go
Neurosurgical transfer
Mobile phone + Phone numbers, Cash + Clothing, Food & For comatose patients (GCS<9) requiring emergent intervention this must occur within 4 hours of the time of injury
Patients likely to be in this group are those with
Kit Check
Transfer bag, with Tracheostomy / Cricothyroidotomy kit Lab Results
If you have checked it … know the result NEVER go without knowing at least Glucose, Potassium, Hb, Monitoring
Minimum for Level 3=As above + Arterial Line + In most Never forget:
Notes and X Rays
NEVER FORGET THE OTHER INJURIES
Medical notes, Nursing notes, Scans and X rays, Transfer Letter for interhospital transfers, Transfer form Vascular transfer
Aortic patients die from uncontrolled bleeding, myocardial
Minute volume = Tidal volume x Rate (Usually 5-15 L/min) infarction, or late, multi-organ failure. Main initial goal is to avoid Requirement = 60 x Minute volume L/h - Can usually assume free rupture, which means you need to reduce “wall tension” – this 600 L/h. This is equivalent to 1 E cylinder (680L) per hour means reduce SBP AND reduce HR (also helps avoid MI) Ambulances usually carry 2 F cylinders – full this is enough “assu me n o t h in g an d t ru st n o o n e ” Allow DOUBLE expected requirement with a buffer of at Avoid volume resuscitation as far as possible, provided Paperwork
Ensure details are filled out on transfer form - It is YOUR Useful antihypertensives include Clonidine, Esmolol, defence against litigation and disciplinary action. It is a legal Take an AMPLE history
Metoprolol, Labetolol, GTN, and SNP. But be cautious and requirement AND bad forms usually correlate with poorly titrate drugs SLOWLY to effect – in the face of hypovolaemia Allergies
responses are likely to be exaggerated. You really must avoid Medications
Past medical history and functional status
Thoracic transection is usually associated with multiple YOU MUST notify: ICU Consultant, Destination to verify that injuries, and often intubation is needed. Last food
Do NOT drain any pleural effusion without first consulting Ambulance - Usually ask for Emergency ambulance will arrive Events leading to transfer / injury / admission
surgeons it may precipitate sudden rupture - if you do- make sure you have lots of X matched blood to hand. “Neurosurgical critical transfer” emergency – state this & you Traumatic pneumothorax may require drainage however Do not delegate these tasks, since Communication is Central Quality Control
Expedite transfer and don’t forget the blood please! Critical incidents - You must fill out incident forms, otherwise it will happen again, and again and again and …. Again. For more details and advice please see the If equipment fails you must identify it, and make a note of the serial number and hospital equipment number and record this on critical incident form and transfer form

Source: http://www.londonccn.nhs.uk/_store/documents/aide-memoire-6pp-dl-v2.pdf

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