**3. Trauma resuscitation, patient management and covid**

One cannot comment on a trauma resuscitation without mentioning the ATLS resuscitation principles [1]. As part of any trauma resuscitation, there are many life- saving procedure that need to be done with urgency under aseptic techniques, as a result trauma resus bays are well stocked with all the equipment within arm's reach [1]. Due to the concern for fomite transmission, some trauma departments changed the layout of their resuscitation area and removing equipment to a different area that is remote from the patient interaction [7]. Livingstone et al. removed all equipment from their trauma resuscitation bays. They designated hot, warm, and cold zones around the patient, where a hot zone involved direct patient contact, a cold zone was a significant distance from patient interaction, where equipment was kept, and the

*DOI: http://dx.doi.org/10.5772/intechopen.103971 Trauma Resuscitation, Mass Casualty Incident Management and COVID 19…*

warm zone was the zone in between hot and cold where equipment was transferred on a table. This was in keeping with the EPA guidelines [7]. Logistically, this would hamper an efficient resuscitation and it can now be seen that it was not necessary due to the lack of fomite transmission [3].

In an effort to conserve PPE, only the staff in the hot zone donned and doffed full PPE, in our setting we also experienced a shortage of PPE and therefore one gown with an N95 and a visor was issued per shift to each healthcare practitioner (shifts lasted either 12 or 24 hours) [7]. However, this can be adapted to the ever-changing PPE protocols [2].

I would like to bring your attention back to our MCI with the low positivity rates. We have a 15- bay resuscitation area with each bay having its own monitors and life- saving equipment. We did not change our resus area at all and again we had low positivity rates (unpublished data). This adds to the evidence for non- fomite transmission [3].

The first focus of the ATLS resuscitation is airway management with its inherent risk for transmission during intubation as an aerosolizing generating event [8]. At the beginning of the pandemic, the use of intubating boxes was advocated. However practically they were not feasible and seemed to hamper airway management [9]. What worked well for us was a video laryngoscope, equipment that was previously not available in our trauma resuscitation area and was reserved for the use by anesthetists [10]. This has also been substantiated in the literature with a meta-analysis [11]. Thus the pandemic benefitted us in that we could hone in on this new skill and gain confidence in the use of it.

COVID positivity or screening never became part of our trauma resuscitation protocols. All patients were treated as PUIs (patients under investigation) meaning their covid status was unknown and all patients that were admitted or required a surgical procedure were tested. If the status of the patient was unknown, they were again operated on a PUIs. We had no dedicated PUIs theater as most acute care surgical and trauma patients were operated on with their covid results being unknown. This was largely due to PCR results turnaround time of about 12 hours if tested after 4 pm and 2 hours if before 4 pm. Surgeons used disposable gowns (a change in the usual theater attire), visors, and masks, which were a N95 instead of a surgical mask. Anesthetic staff occasionally used half-face elastomeric respirator with P100 filters if they were intubating the patient, of note, these were not supplied by the hospital but instead purchased on the own accord of the anesthetist.

Post operatively patients went to the ward which was also a PUI area and only once covid status was known would they be transferred to the covid wards or ICU if a positive result was found. The main nine bed Trauma ICU required a COVID negative result before admission of the patient and therefore a patient would be housed within the ward ventilated and ongoing resus was continued until a result was known and the patient was accepted for admission to the Trauma ICU.

Again, I would like to mention that although our ward was considered a PUI ward, as well as a COVID negative ward as only the COVID positive patients would be moved out once their result was known. We still only had a 9% positivity rate within the unit during our MCI (unpublished data).

In Nigeria, their trauma protocols were adjusted. Patients were screened in their triage area for fever and flu like symptoms not related to their traumatic injury, contact and travel history. Suspected cases were moved to a designated area to be seen by the hospital COVID 19 team (review and testing) while the trauma team continued the resus. Suspected patients were given a surgical mask [5]. This change in protocols

places more emphasis on COVID instead of the traumatic injury. Due to social distancing their resus area capacity decreased from twelve beds to eight beds. The most senior person managed the airway in full PPE. With regards to surgical procedures an N95 and face shield was added to their PPE protocol in theater and the most experienced personnel operated to decrease operative time, hampering training [5]. They again focused on COVID by adding signs and symptoms of covid and travel history to the AMPLE history changing the acronym to SAMPLET. Surgical protocols were also changed, with the focus shifting to COVID, if a patient was covid positive, nonoperative or delayed repairs were encouraged [5]. These decisions should be based on the patient's trauma burden and physiology. We made neither of these changes to our protocols, our focus remained on trauma, the only difference covid made was changing the location of the patient. However, we need to do a formal audit to quantify if our covid positive patients' outcomes were significantly different to their covid negative counterparts. In some areas the trauma burden has decreased with the increase of covid thereby providing us with an ongoing MCI and an approach to this needs to be defined [12].
