ED - Trauma

Question 1

A-E in Trauma Patients (Primary Survey) (Part 1)

Airway (w/ C-spine protection)
Definitive Airway
Breathing and Ventilation
Traumatic Thoracic Injuries

Answer 1

1.) Airway (w/ C-spine protection)
- spinal precautions: hard collar with sandbags and tape, manual C-spine immobilisation until airway control can be achieved
- airway manoeuvres: jaw thrust, chin lift, AVOID head tilt (C-spine)
- airway adjuncts: Guedel (OPA) airway is often used temporarily before the definitive airway, nasopharyngeal airways are inappropriate in head and facial trauma due to the risk of intracranial passage
- suction and Magill’s forceps should be immediately available to remove any foreign bodies in the airway

2.) Definitive Airway - intubation w/ an ET tube with the cuff inflated
- indications: airway obstruction, respiratory insufficiency due to a thoracic injury, shock in multisystem trauma, GCS ≤ 8, penetrating cranial vault injury
- surgical airway (cricothyroidotomy) must be available as a plan B in a ‘can’t intubate, can’t ventilate’ scenario

3.) Breathing and Ventilation
- inspection: external signs of trauma, asymmetrical chest movements
- palpation: over the entire chest wall to reveal any unsuspected injury, assess for tracheal deviation
- consider log roll if concerned about posterior chest wall trauma
- potential interventions: high flow O2, intubation+ventilation, needle or finger thoracostomy, intercostal catheter (chest drain)
- tension pneumothorax can often appear after positive pressure ventilation in trauma patients (small pneumothorax enlarges)

4.) Traumatic Thoracic Injuries
- simple or tension pneumothorax, cardiac tamponade, flail chest
- haemothorax: laceration of lung vessel or internal mammary artery by rib fracture, tx w/ wide bore 36F chest drain (must get vascular access before inserting) OR thoracotomy
- cardiac or pulmonary contusions (common and lethal)
- aortic disruption: commonest cause of death after RTA or falls.
- mediastinal traversing wounds: often from stabbings
- tracheobronchial tree injury: trauma to neck/upper chest (4cm from carina, signs: haemoptysis, surgical emphysema, air leak, TP)
- diaphragmatic injury: often left-sided, surgical repair is required

Question 2

A-E in Trauma Patients (Primary Survey) (Part 2)

Circulation (w/ haemorrhage control)
Disability
Exposure (and environmental control)

Answer 2

1.) Circulation (w/ haemorrhage control)
- systematically look for evidence of bleeding in the chest, abdomen, retroperitoneum, pelvis, long bones and externally
- removal of all pre-hospital bandaging and clothing
- ‘trauma bloods’: routine + crossmatch, VBG, clotting, glucose, lipase
- give 1-2L STAT of IV fluids in (>16G cannula, grey), change to blood if obvious signs of bleeding or still unstable after 2L of crystalloid
- haemorrhage control: temporarily control any external bleeding with direct pressure, tourniquets or by tying off vessels

2.) Disability - GCS, pupils, glucose
- assess gross motor and sensory function in all 4 limbs
- full neurological assessment if suspecting spinal injury
- treatments: seizures, hypoglycaemia, anxiety/agitation, raised ICP
- ICP Mx: 30° head up positioning, analgesia and sedation, mannitol or hypertonic saline, neuromuscular blockade, ?surgical decompression

3.) Exposure (and environmental control)
- completely expose the patient (while maintaining thermostasis)
- consider log-rolling the patient now
- essential areas that can be missed: back of the head, back, buttocks, perineum, axillae, skin folds
- cutting the patient’s clothes is not mandatory or always necessary