Adult Haemorrhage Flashcards
Major Trauma Care objectives
- Immediate control of major haemorrhage
- Ensure
- Airway patency
- Breathing (adequate oxygenation and ventilation)
- Circulation (adequate perfusion for patients presentation) - Prioritise transport
- Supportive care as required
Supportive care flow chart in MT
- Warm the patient
- Pain relief (as required)
- Spinal immobilisation if required
- Mx wounds / fractures
- Seizures as per seizure CPG
- Hypoglycemia as per CPG
- Pressure care
Tranexamic acid indication and dose in MT
- Severe injuies with BP < 90 or COAST score > 3
AND - < 2 hours since injury
- Dose 1g over 10min or IM
COAST SCORE encompasses in MT
- Entrapment
- SBP
- Temp
- Major chest injury likely to require intervention (e.g. chest decompression, chest tube)
- Likely intra - abdominal or pelvic injury
Circulation SHOCK SBP aims in MT
- NON TBI - SBP 70 - 90
- TBI - SBP 120
If suspected both Haemorrhagic and TBI priority is to prevent secondary brain injury associated with hypotension
First priority in Major trauma
- Haemorrhage control should be prioritised.
- Regular pt reassessment to ensure haemorrhage remains controlled
Haemorrhage control notes and reassessment points for MT
- Control of major haemorrhage is an absolute priority throughout the entire episode of care
- Dressings and torniquets may become dislodged
- A pelvic splint may be forgotten or improperly positioned
- Bleeding may resume as a patient resuscitated and their BP increases
- These may not be immediately recognised if pt is obscured (under blanket etc) Full reassessment is essential
Airway notes for MT
- Airway manoeuvres and positions as per CWI
- NPAs should be inserted only if required to maintain a patent airway
- OPAs may provoke a gag reflex and as such should not be used unless airway cannot be maintained with other measures.
- RSI - Identify candidate and initiate the process of RSI early to minimise scene time
Breathing notes for MT
- Oxygen as per oxygen therapy CPG or ventilation as required
- Consider nasal ETCO2 in major trauma pts who do not require active airway management
- Refer to Chest injury CPG for chest decompression indications
- Oxygen is thought to be appropriate in initial phases of critically ill or unstable pt
- Hypoxia may go unnoticed and untreated if pulse oximetry is unreliable or clinician is task saturated.
With a trauma pt the eveidence shows that once the patient is stable you should consider titrating O2 - Capnography allows for monitoring of RR and ventilation trends.
- increasing RR indicates a deteriorating pt either emerging / worsening shock or respiratory failure.
- increasing CO2 likely indicate hypoventilation due to head or chest injury
Circulation notes for MT
- Fluid resuscitation when Pt meets the SBP
-Shock without TBI 70-90 - Shock with TBI >120
- 250 ml IV (max 2L)
- Consult AV med adviser if inadequate response
- Pelvic splint, if blunt trauma to the pelvis or for unconscious multi trauma pt
- Consider other causes of shock (haemorrhage control, chest decompression, pelvic splint, ventilator strategy, anaphylaxis to medications)
Vasopressors reserved for extremely shocked pts where fluid resus has failed and pt in decline)
Factors influencing BP target for pt without TBI in MT
Lower BP appropriate
- Presence of radial pulse
- Normal mentation
- Penetrating truncal trauma
- Young, healthy
- Active, massive bleeding
- Shorter transport times
- NaSaline only fluid available
Shock with TBI Notes
Target BP >120
- Where both TBI and haemorrhagic shock are present, priority to prevent secondary brain injury assoc with hypotension
- Suspect TBI in any multi trauma and LOC or altered Concious state, agitation, or a POI/MOI suggests possiblity of head injury. If any doubt exists target higher BP rather then permitting lower BP.
- Mica may progress to vasopressors to assist BP, once fluids Na saline (plus blood products Mica)
Other considerations for fluid in MT
-Extreme tachycardia, consider fluid resus regardless of SBP if transport time is prolonged or prior to intubation
- Hypotension from isolated SCI should be treated as per spinal injury CPG
Supportive care notes in MT
These cares should run parallel to other aspects of care
- Warm the patient
- prevent heat loss
- ambulance heater
- remove wet clothes
- blankets
- chemical warming blanket
- warm fluids
Spinal immobilisation
- apply collar post RSI
- consider position 10-15 degrees if TBI / chest injury
Tranexamic acid
- Administration is time sensitive but not urgent
- Administer if time from injury is less then 2 hours and either
* any trauma patient with coast greater then 3
* Suspected severe injuries and hypotension
Hypocalcaemia
- If point of care is available iCa should be measured as early as practicable in patients with haemorrhagic shock
- Calcium gluconate 10% may be administered empirically
Agitation *mild - moderate think pain relief
*severe agitation think ketamine as per behavioral disturbance
if shock consider half dose
Non-Traumatic cause of Major Haemorrhage
- AAA or massive GIT haemorrhage** fluid resus and vasopressors as per this guideline TXA not indicated for this
- PPH manage as per PPH guideline
Risks associated with giving fluid in MT
- Dilutional coagulopathy
- increased bleed due to clot disruption and increasing hydrostatic pressure
-Hypothermia (where ambient fluids are given) - resusitation related complications (ALI/ARDS, abdominal compartment syndrome)
PPH management Fundus firm
- High flow O2
- BP <90
- titrate Na Saline 40ml/kg
- consult for further fluid, if unavailable an additional 20ml/kg - Pain relief as per CPG
- Mx any visible lacerations
PPH fundus not firm management
- Manage as per fundus firm
- O2, BP/Saline, Pain relief, laceration mx
- Avoid fundal massage prior to placenta delivery
- If req massage fundus w cupped hand
- Encourage Mo to pass urine
- Encourage baby to suckle breast
- If fundus remains not firm Oxytocin 10iu IM repeat at 5/60 if req’d
- TXA 1g over 10 min
- If haemorrhage is itractable - external abdominal aortic compression
- PIPER if not already contacted
ARDS
Acute respiratory distress syndrome often caused by fluid in lungs
Quick clot indications and contraindications
- Indications
** Uncontrolled haemorrhage from a non compressible wound site
** Unable to control haemorrhage by using direct pressure or a combat torniquet - Contraindications
** Bleeding that can be controlled using basic first aid measures
** Ocular trauma
*** Chest or abdominal wounds
(dressing is unlikely to make contact with point of bleeding) - Precautions
*** Neck wound, packing gauze into a wound may risk compromising the airway.
NOTES
- must contact point of bleeding to be effective
- Apply direct pressure for 3 minutes
Pelvic splint (SAM SPLINT) indications and contraindications
- Indication
***Suspected pelvic fracture - Contraindication
** Impaled object preventing application
** Isolated neck of femur fracture.
-Precaution
** Apply pelvic splint before traction splint if using both
** Ensure position over greater trochanters (often placed to high)
***Application may cause significant pain (Ensure pain relief)
CT-6 traction splint indications and contraindications
- Indications
** Middle third Femur fractures inc compound
** Upper 2/3 of Tibia frac inc compound - Contraindications
*** Knee or ankle/foot trauma
Haemorrhage control direct pressure
Indications
- Uncontrolled external haemorrhage
NO Contraindications
Differentials for adult Haemorrhage
- Stroke
- Fracture
- Aneurysm
- Bleeding disorder
- GI bleed
Focused assessments
- Neurovascular assessment
Differentials for Pelvic injury
- NOF
- Dislocation
- Fracture
Adult haemorrhage clinical risks of deterioration
- Hypovolaemic shock
- Arrythmias
- Limb threat
- Coagulopathy
