1.3 Trauma Flashcards
Describe the CABCDE approach to trauma (primary survey).
- Cerebral perfusion
- Early operative intervention
- Tourniquets, controlling haemorrhage
- Compressions
- Airway (+ C-spine control)
- Manual inline C-spine stabilisation (MILS) is now preferred to hard collars due to risk of aspiration, increased ICP and poor evidence for improved outcomes
- Select the airway adjunct, consider if definitive required, consider surrounding injuries and blood.
- We do not want HI patients to be hypoxic
- Breathing
- 6L/min via non-rebreather mask
- SpO2 measures oxygenation, not ventilation does not substitute listening to the chest
- Circulation
- 2x wide bore cannulae in antecubital fossas
- Consider blood products, and perfuse to target systolic BP
- Consider EFAST scan to look for source of bleeding
- Disability
- AVPU
- Pupils - blown pupil indicates 3rd CN palsy from increased ICP.
- Limbs (Can the patient feel/move all 4 of their limbs?)
- Exposure
- Expose top-to-toe to look for injuries and prevent hypothermia
Call early for transfer and retrieval.
Visualise the assessment of a trauma patient in the emergency department, from CABCDE primary survey to secondary survey.
Video demonstration: https://vimeo.com/25867595
What is the target systolic BP for trauma patients?
- For normal LOC in awake patients
- 70-80mmHg SPB in penetrating trauma
- 90mmHg SBP in blunt trauma
- >100mmHg in head injury patient
Do not aim for normal BP.
Is HR or BP the better indicator of degree of haemorrhagic shock?
HR is much more sensitive than BP.
SBP may not fall until loss of 30-40% of blood volume, as compensatory mechanisms fail. It is a late sign of shock.
Describe the format of trauma handover.
What are the key takeaways for the classifications of haemorrhagic shock from the Committee on Trauma of the American College of Surgeons?
- RR and agitation changes early indicators
- HR increase precedes SBP drop
- Urine output is not useful acutely
Question: An 80 y.o. woman presents to ED. She is confused after her fall, with a large haematoma on the back of her head and she is on warfarin.
Question: An elderly patient presents after a fall from 4m and is hypoxic on presentation at 85%.
Should the patient have limited O2 concentration initially because they may be a CO2 retainer?
False.
The patient should have O2, the CXR demonstrates lower lobe bilateral consolidation, the sepsis may have lead to confusion in the patient and hence the fall. We cannot assume the patient is a CO2 retainer.
Start the O2 high, then titrate down.
Question: A 25 y.o. male has a penetrating injury to his abdomen. What is the most correct statement?
Question: A 38-y.o. female presents post MVA with a closed head injury. She appears confused and has GCS 14. She has a minor head injury and can be moved to subacute.
True or false?
Describe the sequence of the secondary survey.
- Head injury
- Thoracic injury
- Pelvic and lower limb injury
- Spinal injury
- Abdominal injury
What are the management steps for catastrophic haemorrhage?
- Stop haemorrhage, prioritise with or above airway control
- CRASH 2 trial, recommends use of tranexamic acid (TXA):
- 1 gm IV slow bolus (1mL has 100mg per minute), given before 3 hours
- Followed by 1 gm over 8 hours
- Resuscitate to target** not **normal BP
- Consider giving blood as opposed to crystalloids, as the latter have no O2 carrying capacity
-
Give blood
- What type of blood?
- O negative immediately
- Type-specific in 10 min
- Cross-matched in an hour
- Massive transfusion protocol from 4 bags onwards, use 1:1:1 ratio (RBC:FFP:platelets)
3.
- What type of blood?
How do you calculate MAP?
What is the target MAP in trauma management?
MAP = P diastolic + 1/3 (P systolic - P diastolic)
Target MAP is 65mmHg. (Minimum required to perfuse the brain, first signs of hypoperfusion are agitation/confusion.)
Question: This man was brought into ED by friends. What is the correct management?
He should be assessed using the CABCDE system and resuscitated.
AND
He should not be given IV resuscitation as a large bolus if he is mentating normally.
Describe the correlation between palpable pulses and estimated systolic BP.
Poor.
Classical ATLS guidelines state the following:
- Carotid pulse only: 60-70mmHg SBP
- Carotid + femoral pulse: 70-80mmgHg SBP
- Radial pulses: >80mmgHg
2 studies were done on these guidelines. Study 1 by Deakin et al found that overestimation of SBP up to 34mmHg was possible. Study 2 by Poulton et al found the following subgroups:
- Group 1 (R+C+F pulses), 83% <80mmHg
- Group 2 (C+F pulses), 83% <70mmHg
- Group 3 (C pulses only), 0% >60mmHg
- Group 4 (R, C, F absent), 67% <60mmHg
Explain how to apply a cervical collar.
Explain how to perform a log roll.
Video demonstration: https://vimeo.com/25449759
The tallest person should have 1 hand on the shoulder and 1 hand on the hip.
Second person should have one hand on the hip and one hand under the thigh.
Third person should have both hands under the calf.
3 hands over, 3 hands under.
The head controller steadies the patient’s head between their elbows and stabilises their arms by gripping onto the trapezius of the patient.
“On, not after three, we will turn the patient 90 degrees towards you, one, two three.”
Explain how to use the Sam Sling.
Video: https://vimeo.com/23033934
- Slip it under the patient without them moving, by pressing it into the bed.
- Strap the patient in, using countertraction to reach desired tension, then will hear clicks.
- Apply velcro strap.
Explain how to use the ‘unilateral clips’ sheet method to stabilise pelvis.
Video provided: https://vimeo.com/23033934
Explain how to use the ‘twist, tuck and clip’ sheet method to stabilise pelvis.
Video provided: https://vimeo.com/23033934
