Personnel of Trauma Service (members of TSEC)

Members of Trauma Service Executive Committee (TSEC) as at 2023

Name	Rank	Department
Dr Wing Chiu DAI	Consultant Director of Trauma Service	Department of Surgery (Chairman)
Dr Theresa LI	CCE	HKWC
Dr Tat Chi TSANG	Consultant	Department of Accident & Emergency
Dr Andy NG	Associate Consultant	Department of Anaesthesiology
Dr Alfred Wong	Associate Consultant	Department of Intensive Care Unit (Adult)
Dr Lai Fung LI	Consultant	Department of Neurosurgery
Dr Colin YUNG	Resident Specialist	Department of Orthopaedics & Traumatology
Dr Kelvin CHOI	Associate Consultant	Department of Radiology
Dr Carolette Gronenewald	Associate Consultant	Department of Surgery
Ms Hay Tai WONG	Nurse Consultant	Trauma Service
Ms Celestine Ng	Trauma Nurse Coordinator	Trauma Service (Secretary)

N.B. Please feel free to contact the TSEC members for suggestions on improvement or quality issues related to Trauma Service.

Primary Trauma Diversion

Trauma Team Activation

Trauma Team Response System

Calling System for Major Trauma

Team Members’ Key Roles and Responsibilities

Roles and Responsibilities of Trauma Team Members

Policy:

1. Team members are responsible for the roles described in the following table.
2. Mutual respect, understanding and cooperation must be observed by all.
3. The ultimate responsibility rests with the trauma team leader.

Radiology Service

X-ray taking in the resuscitation room

• Alert the duty radiographer through the public address system or by phone to come immediately to the resuscitation room.
• Move the X-ray tube to the highest possible level in between shots. Return the tube to parking position immediately after each full examination.
• Resuscitation should continue during X-ray taking. Hence, trauma Team members are encouraged to put on lead aprons for protection, and have the protective side facing the X-ray tube during X-ray taking.
• Comments by radiologists could be obtained on consultation.
• Early notification of trauma case is required before/during meal breaks.

Emergency Ultrasonography

• Urgent ultrasonography is required to detect free fluids in emergency situations by the Trauma Team. It could reduce or avoid unnecessary diagnostic peritoneal lavage in trauma patients.
• During office hours, the radiologist on duty at K3 ultrasound (Ext. 4320) would be called upon to perform emergency ultrasonography for trauma patients in the Resuscitation Room.
• Outside office hours, alert the radiographer on duty at the CT suite (Ext. 4643 or thro’ Ext. 3005). The on-call radiologist would be called upon when indicated.

Emergency CT Scan Service

• All trauma call emergency CT will be performed at AED CT on the ground floor of J block. From 9:00 - 23:00, contact AED CT on-duty radiographer (Dect phone 1579).
  From 23:00 - 9:00, contact AED on-call radiographer (Ext 3005).
• Trauma Team doctor should accompany the patient during CT scan, be responsible for patient monitoring, and to obtain first hand CT findings.
• The on-call/on-duty radiologist should be notified for IV contrast injection. The Trauma Team Leader may give IV contrast according to the DDR guidelines if the radiologist does not respond within 5 minutes of being called.
• Comments on urgent CT scan performed outside office hours may be requested through the radiographer on duty.

Emergency Angiogram

• During office hours, contact on-duty radiologist at angiogram room (Ext. 4615) for arrangement.
• Outside office hours, contact on-call radiologist at CT suite (Ext. 4643) for arrangement.

NB

• Inform the radiographer i/c for any cancellation.
• Refer to the QMH ‘Manual for Clinical and Ward Staff’ for details.

QMH Trauma Transfusion Guideine

PCC Therapy for Warfarin/new NOAC pt

Facial, H&N Trauma

Fluid Resuscitation to Burn

1st 24 hours total fluid = 2-4ml/kg/% of total body surface area (BSA) burned

24-hour Burn Fluid Calculation example
40% total body surface area burn 60kg patient Burn occurred at 10:00 pm
2 x 60 x 40 = 4,800 ml in first 24 hours postburn event 2,400 ml infused by 6:00 am (first 8 hours since burn event) 2,400 ml or 150 ml/hour infused from 6:00 am to 10:00 pm

Admit to Burn unit if BSA≥15%

References
1. ATLS 7th Ed

Drugs used in Rapid Sequence Induction

A) Induction Agents. All agents may drop the BP and cardiac output in major trauma patients. Dosage must be decreased if patients are hypovolaemic or in shock. In “modified rapid sequence induction” the agent is titrated till loss of eyelash reflex occurs.

	Haemodynamics stable	Haemodynamics unstable
Etomidate (Hypnovel)	0.2-0.4 mg/kg	0.1-0.2 mg/kg
Midazolam (Dormicum)	0.1-0.3 mg/kg	0.05-0.1 mg/kg

B) Muscle Relaxants.Should only be used by those trained in airway management. Suxamethonium is contraindicated in hyperkalaemia, chronic muscle wasting, paraplegia, recent burns and other conditions. (Consult reference for full list). Rocuronium should be used only if the airway can be secured and suxamethonium is contraindicated.

Suxamethonium (Scoline)	2mg/kg	2mg/kg
Rocuronium (Esmeron)	1mg/kg	1mg/kg

________________________
*Other drugs like fentanyl, esmolol, thiopentone, propofol and ketamine may be selected by those trained and familiar with their use.
*Propofol or thiopentone may cause severe hypotension in unfamiliar hands whereas etomidate has good cardiovascular stability. Trauma patients who received etomidate have poorer outcome in some studies, but this is not fully established.

Analgesics for trauma patients in A&E

• Do not neglect pain relief in trauma.
• The Attending physician should exercise clinical judgment in individual cases.
• Please consult relevant Specialists for those <2 yr or >70 yr of age, burns and obstetric patients.

Proper assessment

• Resuscitation should have first piroity.
• Avoid giving opioids in unconscious patient and take special cautions for those who have airway or breathing problem.
• A proper pain assessment is crucial. Visual analog scale involves asking the patient to assign a number for their pain intensity from 0 (no pain) to 10 (worst imaginable). VRS involves asking the patient to describe their pain from mild, moderate to severe.
• Most trauma pain is related to musculoskeletal, visceral or nerve injury. Watch out for causes not directly related to the trauma such as angina or compartment syndrome.

Choice of analgesics and their contraindications

• Simple measures such as local ice for soft tissue injuries and immobilization for fractures.
• The choice of analgesics depends on the pain severity and contraindications.

1. Paracetamol(for mild to moderate pain, can be given with NSAID or opioids)
   Contraindications: Liver disease or injury
   Doses:   Oral: 20mg/kg stat, then 15mg/kg q4h (max 4g/day)
            Rectal: 40mg/kg stat, then 30mg/kg q6h (max 5g/day)
   Child:    usual daily max dose 90mg/kg for 48hr, then max 60mg/kg/day
2. NSAID or moderate to severe pain)
   Contraindications
   1. Age >70 or <2 yr
   2. ongoing blood loss or hemodynamic instability
   3. GI ulcer, renal disease, asthma, allergy to NSAID, bleeding tendency or use of anticoagulants
   Dosages of NSAID
   1. Diclofenac (Voltaren)
      Adult oral/rectal: 1mg/kg (50mg) q8-12h or SR 100mg daily
      Pediatric oral/rectal: 1-2mg/kg/day in divided doses
   2. Ketorolac (Toradol injectable)
      Adult iv/im: 15mg q6h for 2 days
   3. Indomethacin
      Adult oral/rectal: 25-50mg tds
      Pediatric oral/rectal: 2mg/kg/day
3. Opioids(for moderate to severe pain)
   Contraindications
   1. Neuro-trauma patients or those with GCS below 13
   2. Airway obstruction or respiratory failure
   3. Hypotension (<90mmHg for adults) or those hemodynamic instability
   
   Dose of opioids highly variable, must be titrated according to individual responses.
   For patients aged >10 and <60 yr
   1. Moderate pain: Tramadol 2mg/kg (oral/ iv/ im) q8h
   2. Severe pain: Morphine 0.1mg/kg (sc/ im) q4h prn (if not shocked)
   Patients aged <10 or >60 yr, chronic renal or hepatic diseases: cut all doses by 50%

Monitoring

• If on strong opioids: 4 hourly SpO2, BP/P, neurological status and any side effects.
• Resuscitation equipment, medications and personnel should be available.
• Avoid immediate transfer out of A&E after giving strong opioid in case hypotension or apnea develops during transfer. (allow 15 mins of close observation first).

Look out for adverse effects and treat accordingly

• Sedation: stop further sedatives or opioids. Consider Naloxone 0.1mg (iv) bolus if other signs of opioid narcosis develops. Remember ABC: always assess the airway, breathing and circulation. Summon help if needed.
• Hypotension: Review general condition and volume status. Opioids rarely induce hypotension but the reduction in pain can unmask the hypovolaemia. Beware of anaphylaxis.

References:

1. Pain management and regional anaesthesia in the trauma patient. Davidson EM et al. Curr Opin Anaesthesiology 2005 Apr; 18(2):169-74
2. Joint Commission on Accreditation of Healthcare Organizations. Comprehesive accreditation manual for hospitals. Chicago, IL: JCAHO; 2001.
3. Drug doses Fourteenth Edition 2008 Collective P/L. Author: Frank Shann
4. Acute trauma pain guideline for the general ward. Trauma advisory Committee, NTE cluster, Hong Kong. Author: MC Chu.

Traumatic Brain Injury

Cervical Spine Clearance

Blunt chest injury/ blunt aortic injury/ blunt cardiac injury

Blunt Abdominal Trauma

Major Pelvic Trauma

Antibiotics for Open Fracture (Adult)

Critical Trauma Patient Flow after Operation

Adult Glasgow Coma Scale

Note:

1. The GCS may be falsely low if one of the following is present – shock, hypoxia, hypothermia, intoxication, post seizure state, sedative drug administration.
2. An intubated and pharmacologically paralyzed patient who has GCS of 3 should be recorded as 3 (TP), indicating that the patient was intubated (T) and pharmacologically paralyzed (P).

Vital Signs of Pediatrics for Reference