Adult Haemorrhage

Question 1

Major Trauma Care objectives

Answer 1

• 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

Question 2

Supportive care flow chart in MT

Answer 2

• 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

Question 3

Tranexamic acid indication and dose in MT

Answer 3

• Severe injuies with BP < 90 or COAST score < 3
  AND
• < 2 hours since injury
• Dose 1g over 10min or IM

Question 4

COAST SCORE encompasses in MT

Answer 4

• Entrapment
• SBP
• Temp
• Major chest injury likely to require intervention (e.g. chest decompression, chest tube)
• Likely intra - abdominal or pelvic injury

Question 5

Circulation SHOCK SBP aims in MT

Answer 5

• NON TBI - SBP 70 - 90
• TBI - SBP 120

If suspected both Haemorrhagic and TBI priority is to prevent secondary brain injury associated with hypotension

Question 6

First priority in Major trauma

Answer 6

• Haemorrhage control should be prioritised.
• Regular pt reassessment to ensure haemorrhage remains controlled

Question 7

Haemorrhage control notes and reassessment points for MT

Answer 7

• 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

Question 8

Airway notes for MT

Answer 8

• 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

Question 9

Breathing notes for MT

Answer 9

• 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

Question 10

Circulation notes for MT

Answer 10

• 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)

Question 11

Factors influencing BP target for pt without TBI in MT

Answer 11

Lower BP appropriate
- Presence of radial pulse
- Normal mentation
- Penetrating truncal trauma
- Young, healthy
- Active, massive bleeding
- Shorter transport times
- NaSaline only fluid available

Question 12

Shock with TBI Notes

Question 13

Other considerations for fluid in MT

Question 14

Supportive care notes in MT