Multiply Injured Patient

Question 1

Pre-alert

Answer 1

• TRAUMA CALL PRE-ALERTS TRAUMA TEAM of PT.
  
  • CODE RED = MASSIVE EXTERNAL HAEMORRHAGE
• TEAM = ED, ANAESTHETISTS, RADIOLOGY, SURGICAL SPECIALISTS
• ASSIGN ROLES + DETERMINE TEAM LEADER
• EQUIPMENT & DRUG SETUP PRIOR TO ARRIVAL

Question 2

Paramedic handover

Answer 2

• TIME of INJURY
• MECHANISM of INJURY - speed, forces involved, deaths of others involved, ejected, damage to vehicle etc.
• SUSPECTED SERIOUS INJURIES
• VITAL SIGNS - check for IMPENDING AIRWAY CRISIS, ANY CARDIAC ARRESTS
• INTERVENTIONS CARRIED OUT

Question 3

Trauma assessment

Answer 3

• PRIMARY SURVEY - ABC - DETECTS + TREATS IMMEDIATE THREATS to LIFE
  
  • Team approach used to allow collateral activity
  • Good non-technical skills essential (CLOSED LOOP COMMUNICATION) + team need to train together
  • ATLS - ABC approach (Airway + C-spine control, Breathing w/ O2, Circulation w/ haemorrhage control, Disability, Expose + Environment)
  • BATLS - C ABC approach (Catastrophic haemorrhage control)
  • ETC - team approach
• SECONDARY SURVEY - IDENTIFIES ALL INJURIES + MORE DETAILED Hx (e.g. PMHx, tetanus status)

Question 4

CATASTROPHIC HAEMORRHAGE CONTROL

Answer 4

External - CAT tourniquets, max. 2hrs to deal w/ bleeding

Question 5

AIRWAY + C-SPINE CONTROL

Answer 5

ASSESSMENT:

* NOISES - SPEECH, GURGLING, STRIDOR
* VISUAL - SWELLING/DEFORMITY ~ FACE + NECK, VOMIT/BLOOD/DEBRIS

AIRWAY MANAGEMENT:

* MANOEUVRES - CHIN LIFT + JAW THRUST
* SUCTION
* ADJUNCTS
* ADVANCED PROCEDURES - INTUBATION CHECKLISTS

C-SPINE:

* ASSUME INJURY in DANGEROUS MECHANISM (fall from height/from stairs, RTA > 50mph), REDUCED CONSCIOUS LVL, INJURY ABOVE CLAVICLES, NEUROLOGICAL SIGNS (numbness etc.)
* IF DISTRACTING INJURY - PROTECT ANYWAY
* CONSCIOUS PT. - NO COLLAR IF IT WILL HURT

Question 6

BREATHING + O2

Answer 6

EXPOSE CHEST:

* LOOK - VISIBLE INJURIES (flail segment, paradoxical movement, wounds), RR, EFFORT/EXPANSION (are they equal)
* FEEL - PALPATE (s/c emphysema - air from lungs going under skin), PERCUSS (e.g. tension pneumothorax)

O2, ANALGESIA, DRAIN

Question 7

CIRCULATION

Answer 7

ASSESSMENT:

* CLINICAL - HR, PALPABLE RADIAL PULSE (if present - systolic BP at least 70), CRT, BP, PULSE PRESSURE NARROWS, URINE OUTPUT (0.5 mL/kg/hr), CONFUSION (brain perfusion)
* BLOOD TESTS - Hb, LACTATE
* IMAGING - USS, CT

SITES of BLOOD LOSS:

* FLOOR - external haemorrhage, need to be stopped immediately
* CHEST
* ABDOMEN
* PELVIS
* LONG BONES - femoral shaft # ~ 1L; tibial shaft # ~ 0.5 - 1L

MANAGEMENT:

* VOLUME REPLACEMENT - IV/INTEROSSEOUS ACCESS, TYPE of FLUID, AMOUNT of FLUID, MASSIVE TRANSFUSION PROTOCOLS (type specific/full cross-match blood asap + platelets + clotting factors)
* MONITORING VOL. REPLACEMENT - VITAL SIGNS, URINE OUTPUT, LACTATE
* LETHAL TRIAD - COAGULOPATHY, ACIDOSIS, HYPOTHERMIA (encourage bleeding as clotting factors don't work well)

Question 8

DISABILITY

Answer 8

NEUROLOGICAL EXAMINATION:

* AVPU
* GCS
* PUPILS - EQUAL, REACTIVE to LIGHT
* TONE + REFLEXES
* LOG ROLL

Question 9

EXPOSE + ENVIRONMENT

Answer 9

• EXPOSE to ALLOW FULL EXAMINATION

* Then COVER + KEEP WARM (avoid coagulopathy) - remember INJURIES can be HIDDEN POSTERIORLY

Question 10

Bedside tests

Answer 10

• ECG - CARDIAC TRAUMA, ARRHYTHMIA
  
  • ARTERIAL BLOOD GAS - quick LACTATE + Hb + ELECTROLYTES
  • URINE DIPSTICK - BLOOD (renal/ureteric injury)

Question 11

Investigations + secondary survey

Answer 11

• USS - FAST SCAN (focused abdominal scanning in trauma - 4 quadrants)
  
  • CT
  • MINIMAL HANDLING - poss. NO LOG ROLL, DON’T SPRING PELVIS (if concerns of pelvic injury - makes situation worse, disturb clot formed), TRAUMA MATTRESS (CT compatible)

Question 12

Transfer + further management

Answer 12

• THEATRE - OPERATIVE MANAGEMENT
  
  • INTERVENTIONAL RADIOLOGY - CONTROL BLEEDING e.g. embolisation
  • ITU - INTRACRANIAL PRESSURE MONITORING