MVA

Question 1

A 29 YOF is BIBA having been extricated from a crashed motor vehicle. The paramedics tell you that she got herself out of the car before they arrived, but she seems confused and disoriented. They have placed her in a cervical collar. How would you assess and manage her?

Answer 1

Impression
Given dangerous and high velocity MOI, this patient is at risk of several potentially life-threatening injuries which need to be urgently assessed for and ruled-out/treated. In particular, am concerned about head injury given confusion

Key injuries being considered;

• Head: intracranial bleeds +/- raised ICP, TBI, base of skull and other facial/skull fractures
• C-Spine: fracture, spinal cord injury
• Other injuries

Goals

• prior to arrival would be arranging a trauma team with specific roles (A, B, C, etc) team leader. Clear resus bay prior to patient arrival, organise materials that may be needed (order trauma pack from blood bank pre-emptively)
• Gain targeted MIST AMPLE hx from ambo’s and begin primary survey of patient
• Provide appropriate supportive and definitive management

Question 2

MVA - MIST handover

Answer 2

Handover

- MIST AMPLE

Question 3

MVA - Primary Survey

Answer 3

Primary survey
A - signs of resp distress. Patent/maintaining? speaking? suction for vomitus/blood as required. avoid chin lift if providing dynamic airway manoeuvres in consideration of C-Spine, avoid NP airway if ?base of skull fractures

B - RR/SP02 monitoring. Assess for air entry, stridor, WOB etc. Assess for major chest injuries: flail chest (paradoxical movements), pneumothorax - administer needle thoracostomy + chest drain

C - BP/HR/ECG monitoring. assess for colour, CRT, auscultate heart sounds. Gain 2x large bore IVC access and take initial bloods: VBG, FBC, UEC, LFT, Coags, CRP, Lipase, forensic alcohol and drug screen. Administer fluids if shocked as bolus then infusion, if bleeding then consider activating MTP or blood transfusion (call for trauma pack)

D - GCS, pupils for ?raised ICP, assess gross motor and sensation. BSL for reduced LOC

E - secondary survey for other injuries, including long roll

Question 4

MVA - History

Answer 4

History

• further collateral history
• MOI, patients past medical history

Question 5

MVA - Exam

Answer 5

Exam

• Vitals
• Secondary survey
• Clear C-Spine
• Tertiary survey (following day)

Question 6

MVA - Investigations

Answer 6

Investigations

• initial as per A to E
• bedside: urine drug screen
• Bloods:
• Imaging: non-con CTB (intracranial pathology), CT Spine, further imaging for any other injuries identified

Question 7

MVA - Management

Answer 7

Management

• resus and assessment as above
• consider early for retrieval to tertiary centre, consult neurosurg/ortho as relevant to patient injuries.

Supportive

• Fluids
• Analgesia
• empirical ABx prophylaxis for patients with injuries requiring surgical intervention or open fractures
• NBM
• VTE prophylaxis
• clear and detailed documentation