Polytrauma

Question 1

A 25-year-old patient presents to the A&E after a road traffic accident. The patient complains of shortness of breath and severe pain in their abdomen.

What is your initial management?

Answer 1

Ensure a trauma call , resus bay, ATLS approach starting with 1ry survey
C-ABCDE

• C-spine
  Triple immobilization, Neck collar, blocks and straps
• Airway
  Speak/Screaming → Clear
  Anaesth to intervene if necessary

assessment of airway
Look: struggle to breath, cyanosis
Listen: snoring, stridor
Feel: breath on hand or cheek if unsure

Management of airway
1. Remove FB
2. Jaw thrust better for C-spine
3. Adjunct: Oro-pharyngeal, naso-pharyngeal
4. Surgical Airway
5. Definitive airway by anaesthetist

Breathing
1. Examine:
a. Look: Trachea position, Accessory Msls, Paradoxical movement, Rib tenderness
b. Listen: asymmetrical air entry, additional sounds
c. Feel: Hyperresonance/dullness
2. RR, O2 sat
3. Sit upright, 15L non-rebreathe mask, ATTACH TO MONITOR
- Needle decompression, Tube thoracostomy, 3 way occlusive dressing
4. ABG, CXR

Circulation
1. Peripheral and Central pulse (RADIAL AND DP/PT), CRT
2. HR, BP
3. Cannula, Bloods, IV fluids, catheter
4. ECG, Massive Transfusion

Sources of bleeding (Floor + 4 more)
1. Chest, abdomen, pelvis, long bones
2. Apply pelvic binder, tourniquets, compression, splinting
3. Bone fractures

Disability
1. Pupils (Neurological Signs lateralization), GCS, LogRoll
2. RBS, Temp
3. IV analgesia, IV antipyretic
4. CT head

Exposure

while avoiding hypothermia

Head to toe → signs or symptoms for Dx

• Escalate & moreIF PATIENT STABLE
  1. Escalate
  2. AMPLE history
  3. CT trauma, FAST, XRays
  4. 2ry survey head to toe exam

Question 2

What can you see on this X-ray?

Answer 2

• Hypodense are on the Left side + compression of the mediastinum indicating → Pneumothorax
• Rib fracture
• Air under the skin indicating → Surgical emphysema

Question 2

What are the Classes of hemorrhagic shock?

Answer 2

Question 3

How would you manage this condition?

Answer 3

A to E + escalation to Surgical/Cardiothoracic team

1. Urgent needle thoracostomy:in the 4th or 5th intercostal space anterior to the midaxillary line*
2. Chest tube insertion

Question 4

How would you manage this patient in haemorrhagic shock?

Answer 4

1. Resuscitate the patient according to the ABCDE approach
2. Stop the bleeding source, if possible
3. Administer fluids, 500 ml Bolus
4. Consider transfusing blood products, if poor perfusion
5. Treat any underlying Cause
6. Escalate care as necessary (HDU, ITU)

Question 5

How to monitor patient’s response to fluid ressuscitation?

Answer 5

1. UOP: 0.5-1.0 ml/kg/hour in adults
2. Vitals: BP, HR, Temp, RR
3. Clinical parameters, i.e. dry tongue, pallor, skin turgor
4. Examination: peripheral warmth, CRT, Mental status
5. Investigations: Hematocrit, CVP

Question 6

What can you see on this CT?

Answer 6

There is a hypodense area in the liver suggesting a liver tear

Question 7

How would you manage this condition?

Answer 7

Conservative management:
- Blood transfusion
- Monitoring of the hemodynamic status of the patient

Surgical management:
- Damage control with perihepatic packing
- Repair
- Resection

Question 8

What are the grades of a liver tear?

Answer 8

AAST (American Association for the Surgery of Trauma) liver injury scale