General Trauma Flashcards
GENERAL INITIAL/PRIMARY APPROACH to major multitrauma:
PREARRIVAL
Trauma team assemble
Prepare roles, equipment, meds, blood
PPE
ON ARRIVAL
Spinal precautions
FULLY EXPOSE
Monitoring on incl. ETCO2
PRIMARY
Identify and control immediate life threats
A:
- GCS –> tube if <8
–> decompress PTx before PPV
- TWELVE C
- Look in mouth –> suction
- Avoid NP if possible BOS
B:
- 100% O2 via NRBM or BVM
-Sucking wounds, paraxodical, crepitus
- If tension:
–> Finger thoracostomy –> 32F tube. (needle to buy time)
C:
- Identify and control external bleeding
- Log roll
- Splint long bones
- Pelvic binder
- Heart sounds/ pulsus ?tamponade (may be absent)
- 2x large bore access (14-16G, IO, RIC, fem)
–> Send VBG (incl. BSL)/BGH/ FBC/UEC/LFT/lipase/troponin/CK/ coags/ BHCG/ BAL
- Immediate blood/ MTP
–> O-neg child bearing, O+ others
–> 20ml/kg crystalloid to buy time
–> Usual HD targets (controversial)
- ECG
CONCURRENTLY
- Trauma series XR: CXR (supine)/ pelvis
- eFAST scan
TWELVE C for neck exam in trauma:
Tracheal deviation
Wounds
Emphysema (subcut)
Larynx
Venous distension (tamponade, tension)
Eosophagus (swallow)
Carotid haematoma
Haemodynamic targets in major trauma.
Controversial.
Previous ‘permissive hypotension’, to avoid disrupting clots, and exsanguination.
–> Wasn’t well evidenced
–> Data that did exist was for penetrating trauma only
–> Unlikely appropriate in TBI
Prob okay to aim for usual perfusion targets (lactate <2, U/O 0.5ml/kg/hr, mentation) without aggressively pursuing
_______
Principles remain:
- Control external bleeds
- Replace volume with blood and factors
- Help the blood clot
- OT early
Trauma scoring systems:
MANY.
Anatomical scores
eg. ISS
Physiological scores
eg. GCS, APACHE III
Combined scores (better)
eg. ASCOT
(Ideally should also account for age, comorbid status)
General role:
- Predict morbidity/ mortality
–> eg. futility, need for ICU
- Triage
–> eg. need for trauma centre
- Same care between centres
- Audit/ research
GCS:
Originally developed in scale form, for serial assessment of neurosurgical patients.
Was never intended for early TBI, nor ED setting.
Modified to score form (scales combined) for use in TBI:
14 - 15 = MILD
9 - 13 = MOD
8 or less = SEVERE
–> retrospectively validated for this.
(NOTE: has never been validated for tox)
_____________
PROS:
- Simple
- Bedside
- Familiar
LIMITATIONS:
- Unilateral deficit
- Children, CALD
- Tox, hypothermia
- ETOH/ drugs- half of trauma!
- Not great interobserver reliability
USE:
Say as scale, as well as score:
*eg. E2 V2 M1”
Motor is best predictor of outcome
TREND is important
Consciousness scales for children:
Modified GCS
- Age < 2 or nonverbal
AVPU
Alert, Voice, Pain, Unresponsive
- Anyone, not just kids
eg. CALD, cog imp
Trauma systems:
Strongly evidenced to reduce mobility and mortality.
Prehospital:
—> getting to correct hospital, fast, with prenotification
ED:
—> trauma call, correct team, allocated roles, preassembled in a specific room layout
—> Primary, secondary, tertiary survey
Inpatient
—> admit to trauma units
—> rehab
Other
Prevention, advocacy, funding, quality improvement etc.
What is trimodal pattern of death in trauma?
Applies to individual patient.
May die:
1- Immediate/ at scene
2- In first couple of hours (usually haemorrhage) <— ATLS target
3- MODS/ SIRS in ICU
Trauma is leading cause of death in what age group?
1-44
Requirements of a level 1 trauma centre:
24 hour availability:
- ALL surgical sub specialties (incl bypass)
- Neuroradiology
- Haemodialysis
Plus:
- Quality improvement/ education in trauma
- Trauma research program
What MECHANISMS should elicit trauma call?
MVA >60km/h
MBA/ cyclist/ pedestrian >30km/h (or child, any speed)
Fatality in same car
Rollover
Ejection
Cabin intrusion
Extrication >30mins
Fall >3m (or child, >twice height)
Explosion
High voltage
What INJURIES should elicit trauma call?
2 or more long bone
Obvious skull #
Suspected cord injury
Penetration to neck, chest or abdo
Flail chest
Seatbelt sign
Pelvic #
Proximal amputation (above knee/ elbow
Burns >10% TBSA (child, 5%)
etc.
What PHYSIOLOGY should elicit trauma call?
GCS 13 or less
Focal neurology
SBP < 90
RR >30 or <10
(or child, any derangement)
Utility of eFAST scan:
Use in: blunt, hypotensive, abdominal trauma
To identify: haemoperitoneum or tamponade
To decide: ?immediate OT
‘e’ also, checks for:
- PTx
90% sensitive, 95% specific for detecting IP blood
Should be done SERIALLY if neg.
Limitations of eFAST scan:
Negative until 500ml (or 250ml in pouch)
Cannot tell location of injury
Cannot DDx blood from other fluid
-(ascites, urine etc.)
Can’t see many injuries
-(solid organ, hollow viscus, diaphragmatic, mesenteric, retroper..)
- Limited views in:
–> obesity
–> bowel obstruction
–> subcut emphysema
Requires experienced operator
REACT 2 Trial:
Total body CT (‘pan scan) vs selective CT scan in major trauma.
RCT, large, multi centre.
Pan Scan did not decrease mortality, but did increase radiation
Ie. We should selectively scan.
MODIFIER: considerations in obstetric trauma
TXA (tranexamic acid) in trauma:
CRASH 2
- Give TXA early (1-3 hours) if bleeding
- Mortality benefit (35% less death from bleeding!)
- No worse VTE
1g IV stat, then 1g IV over 8 hours
