Holley AD Trauma (This is best done with an interactive tutorial) A 33 yr old lady crashes her motorcycle at 80 Km/hr into a stop sign. 1. Given the mechanism, what injuries may have occurred? o
Head injury
o
Cervical, thoracic, lumbar spine injury
o
Chest injurys
o
Intra abdominal injury‐both solid and hollow viscus
o
Pelvic fractures
o
Renal tract injury
o
Long bone injury
o
Soft tissue injury
2. What components of the history would be useful? o
Signs and Symptoms
o
Allergies
o
Medicines regularly taken
o
Past medical history of note
o
Last meal
o
Environment/events‐ Loss of consciousness, wearing a helmet, blood at the scene
At the scene your vital signs are as follows:
Holley AD 3. What are the implications of these vital signs and what would you do if you were a medical practitioner attending with the ambulance service? There are already features suggestive of shock. A‐Ensure her airway is patent & apply a cervical collar B‐ Provision of oxygen at 15 L/min by Non‐rebreather bag mask. C‐ Insertion of 2 x large bore IV catheter i.e. not smaller than 16 gauge. Provision of crystalloid resuscitation fluid. You transport the patient to the emergency department and on arrival in ED her vital signs are as follows: o
Airway maintained
o
RR 26 bpm, SpO2 96% on 15 L/min by NRB. Symmetrical chest movement bilaterally
o
GCS 11/15, no focal neurology, Pupils equal and reactive to light.
o
HR 170 bpm, BP 70/30
4. What would your actions be as the receiving emergency department doctor? o o o o
Primary survey Resuscitation phase Secondary survey Definitive care phase
5. What is the primary survey? Primary survey‐ On initial reception of a major trauma patient, life‐threatening problems are identified and addressed as rapidly as possible. An ABCD approach is utilised.
Holley AD o o o o o
Airway maintenance with cervical spine control Breathing and ventilation. Ensure provision of oxygen. Circulation and control of obvious haemorrhage. Secure reliable large gauge IV access if not already achieved. Disability (rapid assessment of neurological status) Exposure (the patient is completely undressed to allow full examination, but without allowing the patient to become hypothermic)
High‐flow oxygen by mask is given to all trauma patients. However, patients with severe trauma frequently require ventilatory support. A restless, uncooperative patient should be intubated under a rapid sequence induction to facilitate resuscitation. However this procedure should not be performed by untrained medical staff. 6. The primary survey also includes adjuncts, what are they? Continuous monitoring should include pulse oximetry, cardiac ECG monitor, and a cycled blood pressure cuff. Two large‐bore IV lines are placed as blood is drawn for screening tests, including blood type and crossmatch. Nasogastric or orogastric tubes are placed for gastric decompression and to prevent aspiration. A urinary catheter is inserted unless a ruptured urethra is suspected (because of blood at the urinary meatus, severe fractured pelvis or abnormal prostate position on rectal examination), in which case a suprapubic catheter is indicated. Urine output monitoring is an important guide to resuscitation. Radiographs should include : o
cervical spine
o
chest x‐ray
o
pelvic x‐ray.
The patient described has a heart rate of 170 bpm, BP 70/40. 7. What features provide an indication of haemodynamic stability o
Mental status (alert, verbal, pain, and unresponsive)
o
Skin perfusion (pink/warm versus pale/cool)
Holley AD o
Haemodynamic parameters (blood pressure, heart rate).
o
The urine production rates are useful in estimating end‐organ perfusion.
Estimates of systolic blood pressure (SBP) may be gleaned from palpable pulses. The radial pulse estimates SBP > 80 mmHg; Femoral pulse SBP > 70 mmHg Carotid pulse SBP > 60 mmHg. 8. The patient is shocked, consider the possible aetiology of her shock? o
Hypovolaemic‐ obvious or cryptic blood loss
o
Obstructive‐ cardiac tamponade, tension pneumothorax
o
Cardiogenic‐ myocardial contusion or coronary artery injury
o
Distributive‐ neurogenic, anaphylactic related to an agent given in resuscitation.
9. How is the aetiology of shock determined? o
History‐ blood loss at the scene
o
Good clinical examination‐ tension pneumothorax, tamponade, features suggestive of a high spinal injury
o
FAST
o
CXR, Pelvic X ray
10. Hypovolaemic Shock maybe from easily determined or occult sites: External loss which is often obvious, but don’t under estimate loss from scalp lacerations or accumulative sites. o Pleural cavity can accommodate a significant amount of blood and maybe detected on urgent chest X‐ray. Intrapleural drains will reveal the amount and rate of blood loss. o Peritoneal cavity is often a site of bleeding and may be detected by ultrasound (FAST), laparotomy or computed tomography (CT) scan. It is important to recognise that clinical examination of the abdomen can be unreliable especially when the patient is head injured, has a spinal cord injury, is intoxicated or has multiple injuries. Furhermore a single clinical examination is of limited value, it is the changes over time that are more important. o
Holley AD Major fractures, which are obvious clinically by deformity, swelling, crepitus, pain and tenderness (e.g. femurs) or seen on a plain X‐ray (e.g. pelvis). The retroperitoneum is a potential site for significant cryptic blood loss that can be detected at laparotomy or CT. The unstable patient should never go to CT. 11. Describe the class of shock, estimated blood loss and expected signs Class of Shock o
Class I
Class II
Class III
Class IV
Blood loss (mL)*
Up to 750
750–1500 1500–2000 >2000
Blood loss (percent blood volume) Up to 15
15–30
30–40
40
Pulse rate
140
Blood pressure
Normal
Normal
Decreased Decreased
Pulse pressure (mm Hg) 12. What is a FAST?
Normal or increased Decreased Decreased Decreased
FAST describes a Focused assessment with sonography for trauma It is a rapid ultrasound screen for intraabdominal injury and can determine the presence of haemoperitoneum but is highly operator‐dependent. The amount of fluid necessary for a positive FAST remains unclear but, several hundred millilitres of fluid/blood are generally necessary to be well visualised on FAST. FAST is performed in four areas: o
perisplenic,
o
perihepatic,
o
pelvic
o
pericardial.
Regardless of which organ is injured, the perihepatic view is most commonly positive. Blood pools in Morison pouch, the most dependent portion of the abdomen. The pericardial views can be extremely helpful, although pericardial tamponade is rare after blunt abdominal injury.
Holley AD 13. What is the secondary survey? Injuries are easily missed in an emergency, especially when one injury is obvious While resuscitation continues, a secondary survey should be undertaken. The secondary survey is a rapid, but detailed physical examination with the purpose of identifying all the injuries, both major and minor. The examination is literally from top to toe including rectal and pelvic examinations. The medical team can then set logical priorities for evaluation and management. 14. Describe the GCS and how it varies for different age groups Glasgow Coma Scale for All Age Groups 4 years to Adult Child