Acute Care Block - Trauma Module Introduction ( Brief cABCDE reviewing of a patient) ( c = catastrophic external haemorrhage) Flashcards
The assessment and management of the trauma patient requires the rapid identification and correction of life-threatening injuries. Attention is focussed first on those conditions which are most rapidly fatal.
What is the initial aim of managing a trauma patient?
The initial aim of managing a trauma patient is to control any catostrophic external haemorrhage and open the airway whilst immbolising the C-spine
A bried and focused history is important when assessing the trauma patient. In paritcular the mechanism of injury can give an idea of the energy and transfer of energy involved and the possible pattern involved.
What is the good acronym for remembering how to take a quick and good history in an acute scenariio?
A good history is vitally important
An AMPLE history is good in these situations
- Allergies
- Medications
- Past medical history
- Last ate
- Events and environment
The aim of the primary survey is to identify and correct immediate life-threatening conditions.
- Once immediately life-threatening conditions have been treated and resuscitation commenced, a more detailed SECONDARY SURVEY is carried out to detect all the patient’s injuries, no matter how minor.
- Bear in mind that a proper secondary survey may not occur until many hours or even days down the line, once life threatening injuries have been managed.
What is the initial management of a catostrophic external haemorrhage?
The initial management of a catostrophic external haemorrhage is simple direct pressure to the wound or to apply a tourniquet proximal to the open wound site / apply spcialised haemostatic dressings
The primary survey is a prioritised process of assessment and resuscitation. Once identified, each immediately life-threatening abnormality must be corrected before moving on with the assessment. If only a single doctor is present this is done sequentially; however with multiple doctors from the relevant specialties acting under the control of a team leader (as is gold standard), the process is accomplished simultaneously and rapidly.
As said previously, the catostrophic external haemorrhage must be dealt with first
How many people are needed to effectively imbbolise a head/neck and size for a C-collar?
2 people are required - 1 to immbolise the head and neck and the other to efficiently measure for a correctly sized collar
C-SPINE IMMBOLISATION
State how a C-spine collar is measured and fitted for patients who require C-spine immobilisation? (the link for a video explaining the process is attached below)
https://www.youtube.com/watch?v=cYxnp6ml8mE&ab_channel=laurathamtube
- Rescuer 1 - immbolises head and neck by placing thumbs pointing to jaws anterior to the ear, and the fingers behind the ear on the occopital bone
- Rescuer 2 – measures size of collar – measure gap between jaw and collar using hand width, then put this width on the cervical collar and adjust the collar appropriately and lock it in position. Often easier to slip through the rear part of the collar first round the back of the casualty’s neck
- Throughout the whole time and even after the collar is fitted, rescuer 1 should continue to immobilise the head and neck
An occluded airway will kill a patient in 3 minutes. Movement of the C-spine whilst openning the airway could in theory damage a previously intact and spinal cord and therefore measures should be taken to immbolise the C-spine.
What were the discussed measures for immbolising the C-spine on the previous card?
Initially in-line immbolisation using one person’s hands and followed subsequently with a semi-regid and appropraitely sized cervical collar (and blocks and tape)
Is a normal CT scan enough to clear a neck in an unconscious immbolised patient?
What should all trauma patients be given?
A normal CT scan cannot totally clear a neck in an unconscious immbolised patient
All trauma patients should be given oxygen at maximal concentration through a well fitting mask at 15 lites/min (high flow oxygen 15l/min through a non-rebreather)
How is airway patency assessed in a patient?
What would indicate the person has a clear away?
What would indicate a partially or completely obstructed airway?
Airway patency is assessed by speaking to the patient and listening/looking for movement of air
Patients who vocalise normally have a clear airway
Noisy breathing may indicate a partially obstructed airway
No airway movement at all may indicate a completely obstructed airway
Initially simple interventions are used to clear the airway
What are these?
The mouth should be searched for obstructing foreign bodies or fluids, and suction with a Yankeur catheter is used to remove any blood or secretions - avoid blind suctioning, only suction what you can see
If the simple airway interventions fail to clear the airway, simple manoevures are tried.
What is the commonest cause of airway obstruction? - what is the simple manoevure option to attempt to treat this?
The commonest cause of airway obstruction is the tongue occluding the airway by falling onto the posterior pharyngeal wall
- A jaw thrust pulls the mandible - and therefore the tongue - and is the preferred manoevure
- A chin lift is a possible alternative manoeuvure but care should be taken to avoid head tilt in patients with C-spine injury
If the simple measures are unsuccessful (both simple interventions and manoeuvres), or if the obstruction recurs when the airway manoeuvre is release, the next step is to try airway adjuncts.
What are the two options here and when is one of the contraindicated?
Airway adjuncts include oropharyngeal (guedel) or nasopharyngeal airway.
A nasopharyngeal airways should be avoided in patients with potential base of skull fracture or signifcant facial fractures - this is because these fractures may allow for a route of entry to the brain and therefore trying to push this airway in could cause serious damage
Is a guedel well tolerated?
A guedel airway will be poorly tolerated in conscious patients and will generally only be tolerated in patients with a GCS = 8
In a trauma patient, simple airway interventions/manoeuvres and airway adjuncts are temporary solutions until a definitve airway can be established
What is used as a defintivie airway?
When may a surgical airway be required?
A cuffed endotracheal tube is generally how a defintiive airway is achieved
In rare circumstances of upper airway obstruction or major facial trauma or laryngeal trauma, it may be necessary to create a surgical airway - tracheostomy is the preferred method
BREATHING
Major chest injurites can result in both hypoxia and hypovalaemia. Immediate life-threatening conditions are recognised clincially without the need for Xray in the primary sirvery.
What are the immediate life-threatening chest injuries detected in the primary survery? (acronym - ATOM FC)
ATOM FC
- Airway obstruction
- Tension pneumothorax
- Open pneumothorax
- Massive haemorrhage
- Flail chest
- Cardiac tamponade
The six immediate life-threatening chest injuries may be detected and must be managed in the primary survey.
The principles of method of treatment are usually simple and broadly the same.
What do they include?
What is the aim of these interventions?
The methods of treatment usually include oxygen, decompressing the pleural space with a needle or chest drain, IV fluid/blood replacement and in some instances, ventilatory support
The goal is to correct hypoxia and hypovalaemia
In the sickest of patients and those in extremis, a CODE RED / MASSIVE HAEMORRHAGE PROTOCOL may be activated. This can be done on arrival of the patients in rhesus or pre-hospital and involves emergency delivery of a ‘SHOCK PACK’
What does the SHOCK PACK contain?
What can be given to the patient within 3 hours of injury and why?
The SHOCK PACK contains 4 units of O negative, Rhesus negative blood, 4 units of Fresh Frozen Plasma and a pool of patients blood.
- In patients requiring massive transfusion, this should be done at a ratio of 1RCC:1FFP
1gram of IV tranexamic acid can be given to patients with or at risk of significant haemorrhage following trauma if within 3 hours of injruy
How is the AVPU scale calculated?
State each part of the sections of the Glasgow Coma Scale?
Alert, responds to Voice, responds to Pain, Unalert
Glasgow Coma Scale - total score out of 15 (min score = 3)
- Eye response - out of 4
- Verbal response - out of 5
- Motor response - out of 6
Special considerations myst be remembered to certain patients presenting with trauma
When would you carry out a CT head scan in adult trauma patients?
(the link to the NICE guidelines on when to CT scan - for adults and children https://www.nice.org.uk/guidance/cg176/resources/imaging-algorithm-pdf-498950893)
For adults who have sustained a head injury and have any of the following risk factors, perform a CT head scan within 1 hour of the risk factor being identified:
- GCS less than 13 on initial assessment in the emergency department.
- GCS less than 15 at 2 hours after the injury on assessment in the emergency department.
- Suspected open or depressed skull fracture.
- Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
- Post-traumatic seizure.
- Focal neurological deficit.
- More than 1 episode of vomiting.
