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
