Mini Symposium: The Multiply Injured Patient Flashcards
why is trauma important?
- Death - Leading cause for first four decades of life.
- Disability - For every death - two survivors with significant disability
Not always high energy mechanism
Silver trauma cases rising (older generation – high and low velocity)
is trauma care new?
No
- Conflict often leads to advances in trauma care.
- WW1:
- Thomas splint introduced. (management of femoral fractures)
- Mortality rate in femoral fractures 80% - 8%
- Still used today
what are the steps involved in good quality trauma care?
what is a major trauma centre?
- Good trauma care involves getting the patient to the right place at the right time for the right care.
- A Trauma Network includes all providers - pre-hospital services, smaller local trauma units and larger trauma centres and rehabilitation services
- Major Trauma Centres: centres of excellence providing multi-specialty hospital care to seriously injured patients, optimised for the provision of trauma care
what is a pre alaert and what hapens cause of this?
- A Trauma call pre-alerts the trauma team of a patient
- Team is made up of ED, anaesthetics, radiology, and surgical specialities
- Assign roles
- Equipment and drug set up takes place prior to arrival
what is involved in and what information is given in a paramedic handover?
What information do you want to get from paramedics?
- Time of injury
- Mechanism of injury - speed/forces involved/deaths of others involved/ejected/damage to vehicle etc
- Suspected serious injuries
- Vital signs
- Interventions carried out
Identifies patient status
how is a trauma assessment done?
- Primary survey - ABC - detects and treats immediate threats to life
- Secondary survey (after patient has been stabilised and kept alive) - Identification of all injuries and more detailed history
how is a primary survey carried out?
- Although priorities are in a set order in reality a team approach is used
- This allows collateral activity
- Team leadership and communication is vital
- Good non-technical skills are essential
- Team need to train together
what things are involved in the primary survey?
ATLS (advanced trauma life support) - “ABC” approach:
- Airway with C-spine control
- Breathing with O2
- Circ. with haemorrhage control
- Disability
- Expose and environment (D and E part of secondary survey)
BATLS (Battlefield advanced trauma life support):
- “<c> ABC”</c>
- Catastrophic haemorrhage control
what is Catastrophic haemorrhage control?
- Haemorrhage leading cause of death in military trauma. (ballistic/explosive)
- Delays in treating haemorrhage while assessing A and B led to deterioration
- Novel ways of stopping/reducing haemorrhage led to large increase in survival
ABC approach is traditional. May hear about CABC – used in military - treat catastrophic haemorrhage first – no point securing airway if they have bled out their entire blood volume during this time. Like most military medical advances, this approach of CABC is becoming common practice in our EDs too
Again in reality in major hospitals collateral activity happening – someone dealing with airway whilst someelse putting tourniquet on
Catastrophic haemorrhage (external) - what is done?
CAT tourniquets are now common place in Eds
Airway and C-spine control - how is assessment done?
Noises:
- Speech
- Gurgling
- Stridor
Visual:
- Swelling/deformity
- Vomit/blood/debris
Airway and C-spine control - what is the airway management?
Manoeuvres
Suction
Adjuncts
Advanced procedures (intubation checklists)
when would you assume C-spine injury?
(give neck support)
•Assume injury in:
- Dangerous mechanism
- Reduced conscious level
- Injury above clavicles
- Neurological signs
- If distracting injury(s) care in clinical assessment
Breathing and oxygen - what needs to be done?
Expose the chest:
- Look
- Visible injuries
- RR
- Effort/Expansion
- Feel
- Palpate
- Percuss
- Listen - auscultate
Oxygen, analgesia, drain
Look to see if any areas don’t expand
Drain can be put in chest to drain out blood and air
how is circulation assessed?
• Clinical:
- Heart rate
- Palpable radial pulse
- CRT
- BP
- Pulse pressure narrows
- Urine output
- Confusion
- Blood tests - HB (haemoglobin), Lactate
- Imaging - Ultrasound, CT
Circulation - what are the 5 areas for blood loss?
Floor
Chest
Abdomen
Pelvis
Long bones
C - how is haemorrhage controlled at the pelvis?
Compression
Fractured pelvis is a big bleeding area
Pelvic binders to compress the pelvis and stop blood bleeding into it
Circulation - how is volume replacement done?
- IV access
- IO access (put into bone, useful in children)
- Type of fluid
- Amount of fluid
- Massive transfusion protocols
Circulation - how do you monitor volume replacement?
Vital signs
Urine output
Lactate
Circulation - what is the lethal triad?
Coagulopathy
Acidosis
Hypothermia
how do you assess disability?
•Neurological examination:
- AVPU
- GCS
- Pupils
- Tone and reflexes
- Log roll
Remember during primary survey this is a brief neuro exam to detect any major abnormalties – more detail exam takes place in secondary survey
In certain cases we will scan patient on special CT compatible scoop or matress so no log roll is performed before scan
Expose and Environment - what is involved?
- Expose to allow full examination
- Then cover and keep warm
Remember injuries may be hidden posteriorly
Log roll to look for problems
what is DEFG?
•Don’t ever forget glucose
Don’t know if the person is diabetic or not and if it is involved in their injury
what bed side tests should be done?
- ECG - ?blunt cardiac trauma ?cause of collision (eg syncope)
- Arterial blood gas - electrolytes, Hb, lactate
- Urine dipstick - haematuria suggestive of renal / ureteric trauma
what is involved in Investigations and Secondary survey?
Traditionally:
Primary survey x-rays:
- C-spine
- Chest
- Pelvis
Secondary survey:
- Log roll
- “Spring the pelvis”
- Check all orifices – PR etc.
Modern approach:
Ultrasound:
- Fast scan (look for free fluid or bleeding in pelvis or pericardium)
- CT
Minimal handling:
- Possibly no log roll
- Trauma matress
- Don’t spring the pelvis
what Transfer and further management would be done?
- Theatre - Operative management
- Interventional radiology - Control of bleeding
- ITU - Intracranial pressure monitoring
Summary:
- Trauma is the major cause of _____ in young people
- A _______ survey using a standardised ABC (CABC) approach allows identification and treatment of life threatening emergencies
death
primary
