Current guidelines

Question 1

Management of Airway (pre-hospital & hospital)

Answer 1

• Intubation
  Use RSI as a definitive method to secure airway if patient can’t maintain their airway or ventilation. Aim to perform RSI within 45 minutes.
• If RSI fails
  If RSI fails basic air manoeuvres and adjuncts, or a supraglottic device to maintain airway.
• If RSI cannot be completed at all;
  • Use a supraglottic device if the airway reflexes are absent.
  • Use airway manoeuvres and adjuncts if airway reflexes are present (or supraglottic not possible)
  • Transport to a major trauma centre for RSI if journey is less than 60 minutes. If journey is more than 60 minutes or airway cant be maintained, transport to trauma unit for RSI bfore directing to major trauma.

Question 2

Management of chest trauma (pre-hospital)

Answer 2

• Use clinical assessment to diagnose pneumothorax for triage or intervention. Use eFAST to aid clinical assessment only if specialist team with equipment is immediately available and onward transfer wont be delayed. A -ve eFAST doesn’t mean -ve for pneumothorax.
• For a tension pneumothorax only, only perform chest decompression if there is haemodynamic instability or severe respiratory compromise. Use open thoracostomy if expertise would allow, followed by a chest drain on those with spontaneous breathing. Observe patient in case of reoccurrence.
• For patients with open pneumothorax cover the site with simple occlusive dressing and observe for tension pneumothorax.

Question 3

Management of chest trauma (hospital)

Answer 3

In patients with tension pneumothorax, only perform chest decompression before imaging if there is haemodynamic instability or severe respiratory compromise. Perform open thoracostomy followed by chest drain in patients with tension pneumothorax.

Question 4

Management of chest trauma (hospital; IMAGING)

Answer 4

• Imaging chest trauma would be performed urgently and should be interpreted immediately by a professional with skill in this area.
• Consider immediate chest x-ray or eFAST scan for chest trauma with severe respiratory compromise (16+ years).
• Consider immediate CT scan for patients with chest trauma without severe respiratory compromise and responding to rescucitation, or whose haemodynamic status is normal (16+ years).
• Consider chest x-ray or ultrtasound as first line for chest trauma in children (under 16).
• Do not routinely use CT as first line imaging in children with chest trauma.

Question 5

Management of heat loss (pre-hospital + hospital)

Answer 5

• Minimise ongoing heat loss in patents with major trauma.

Question 6

Management of pain (pre-hospital)

Answer 6

Pain assessment
- Assess pain regularly using pain assessment scale suitable for the age, developmental stage and cognitive abilities.
- Continue to assess using same pain scale that was used in. Pre-hospital setting.

Pain management
- For patients with major trauma use morphine as first line analgesic IV and increase dose until adequate panrelief is achieved.
- If IV access is not achieved use diamorphine or ketamine (only use analgesic dose as second line agent) by atomised delivery intranasally.

Question 7

Benefits of CT in major trauma

Answer 7

• It is readily available, some hospitals may have multiple CT machines
• CT machines are able to demonstrate fresh bleeding
• Rapid scan times
• Axial images allow for 3D reconstruction
• Able to provide multi planar reconstructions

Question 8

Disadvantages of CT Major trauma

Answer 8

• High dose associated with the procedure
• Risk to patient when having to transfer them to the CT machine

Question 9

Management of haemorrhage (Imaging)

Answer 9

• Imaging for haemorrhage in patients should be performed urgently and interpreted immediately by a professional of that area.
• Limited diagnostic imaging, (eg. Chest and pelvis x-rays, or FAST) to the minimum needed to direct intervention in patients with suspected haemorrhage and haemodynamic instability who aren’t responding to blood volume resuscitation.
• Beware a -ve FAST doesn’t rule out intraperitoneal or retroperitoneal haemorrhage.
• Consider immediate CT for patients with suspected haemorrhage if they are heamodynamically stable and are responding to volume resuscitation.
• Do not use FAST or other imaging before immediate CT in patients it’s major trauma haemorrhage.
• Do not use FAST as a screening modality to determine whether a patient needs CT in major trauma.