Major Trauma

Question 1

Common mechanisms of injury in major trauma

Answer 1

-Fall from height
=Foot and spine
=61% frontal impact, 26% side, 8% rear, 5% other (including rollover)
-Road traffic collisions
=Head: windscreen/ front pillar/ intruding
=Most severe head and chest: contact with steering wheel
=Legs: footwell intrusion
=Minor bruises and chest abrasions from seat belt webbing

Blunt: RTC, fall from height, assault
Penetrating: stab gunshot
Other: burns, inhalation, near-drowning, electrocution

Question 2

What is Major Trauma?

Answer 2

-In injury or combination of injuries that are life-threatening and or life changing

Question 3

Patient factors

Answer 3

-Age: child/ elderly/ pregnant
-PMHx
-Medications
-Drugs/ alcohol/ illness precipitating trauma

Question 4

Catastrophic haemorrhage management

Answer 4

-Stop any significant haemorrhage
=Direct pressure
=Haemostatic gauze (help blood clot)
=Tourniquet (beware limited time due to distal ischaemia- 2 hours)
=Splint- long bones

Question 5

Airway management

Answer 5

-Protect c-spine (MILS manual inline stabilisation, collar, blocks and tape)
-Basic: avoid head tilt/chin lift, jaw thrust, OP airway, NP beware basal skull), iGel or LMA
-Intubation: indications, within 45 mins of contact with medical assistance if required (aware if risks of anaesthesia agents in hypovolaemic/shocked patients)
-Surgical airway

Question 6

Breathing assessment and management

Answer 6

-Sats, RR
-Trachea
-Look: bruising/ asymmetry/ flail segments, if penetrating inspect back
-Feel: chest wall movement, crepitus, surgical emphysema
-Listen: air bilaterally

-Needle decompression: only if haemodynamically unstable/ significant resp compromise and thoracostomy not available
-Finger thoracostomy preferred followed by chest drain

Question 7

Circulation

Answer 7

-Assess: HR, BP, CRT, pulses and peripheries feel
-Blood loss: floor +4 (chest, abdo, pelvis, long bones), direct pressure/immediate wound management, pelvic binder, traction splint, don’t forget max fax haemorrhage (bite blocks, epistats, c-spine, splint)
-Replace volume: 2x large bore cannulas/ IO, blood BTS, VBG (lactate= perfusion), blood not crystalloid, 1:1 ratio RCC to FFP
-Permissive hypotension (beware head injury)
-Tranexamic acid if within 3 hour head injury (bolus 1g, infusion 1g)

Question 8

Disability

Answer 8

-GCS
-Pupils
-BM
-External evidence of head injury
-Mainstay of initial management of head injury is normalising physiology and preventing secondary injury
-If patient unable to comply; gross neuro

Question 9

Environment and exposure

Answer 9

-Triad of death (acidosis, hypothermia, coagulopathy)
-Prevent hypothermia: warmed blankets, warmed fluids/blood, bear hugger
-Abx for open fractures and tetanus prophylaxis
-Adjuncts to primary survey: radiology, ECG