Polytrauma Flashcards
Airway management as per ATLS long answer
A - airway and c-spine control.
Assess airway patency → Protect cervical spine → Clear obstruction → Open airway → Definitive airway management if needed → Confirm airway placement.
- Assess Airway Patency
Look, Listen, and Feel:
Look: for signs of obstruction — blood, vomit, secretions, facial trauma, burns, foreign body.
Listen: for noisy breathing — stridor, gurgling, snoring (suggests partial obstruction).
Feel: airflow at the mouth and nose.
Is the patient able to speak?
- If the patient can speak in full sentences, the airway is patent.
- If the patient cannot speak, the airway may be compromised.
Obvious signs of airway compromise:
Agitation (early hypoxia) or drowsiness (late hypoxia).
Accessory muscle use, suprasternal/supraclavicular retractions.
Cyanosis.
- Protect the Cervical Spine
Assume cervical spine injury in any trauma patient until proven otherwise.
Apply manual in-line stabilization (MILS) immediately.
Use a sandbags and tape and secure the patient on a spine board as needed. - Clear the Airway
If there are obstructions:
Suction blood, secretions, or vomitus.
Remove obvious foreign bodies manually (e.g., using Magill forceps if visible). - Open the Airway
If airway obstruction persists:
Basic maneuvers: jaw thrust (preferred), or chin lift if no concern about c-spine.
If basic maneuvers fail:
Oropharyngeal airway (OPA) if the patient is unconscious (no gag reflex).
Nasopharyngeal airway (NPA) if the patient is semi-conscious or has an intact gag reflex — but contraindicated if base of skull fracture is suspected.
- Definitive Airway Management
If airway cannot be maintained, or if the patient needs prolonged ventilatory support:
Endotracheal intubation (with in-line c-spine immobilization).
If intubation fails or is not possible:
Surgical airway (e.g., emergency cricothyroidotomy in adults).
In children, needle cricothyroidotomy or surgical tracheostomy (different anatomy).
- Confirm Tube Placement (if intubated)
End-tidal CO₂ monitoring (gold standard).
Auscultate both lungs and over the stomach.
Observe chest rise and fall.
Secure the tube.
indications for definitie airway
Airway obstruction.
Breathing failure.
Circulatory collapse (severe shock requiring airway control).
Disability (low GCS ≤8: unable to protect airway).
Expectation of deterioration.
10 second quick fire airway management
“In a trauma patient, I would manage the airway systematically following an ATLS approach:
First, I would assess airway patency while maintaining full cervical spine protection.
If obstructed, I would clear the airway with suction and basic maneuvers (jaw thrust preferred).
If still compromised, I would insert airway adjuncts appropriately — oropharyngeal or nasopharyngeal depending on GCS and skull injury risk.
If a definitive airway is needed, I would proceed to endotracheal intubation with in-line stabilization, confirming placement with end-tidal CO₂.
If intubation fails, I would be prepared for an emergency surgical airway such as cricothyroidotomy.”
Breathing assessment as per ATLS
“Expose the chest, inspect, palpate, percuss, auscultate. Intervene immediately if life-threatening injuries are found. Give high-flow oxygen and request appropriate imaging.”
- Expose and Inspect
Fully expose the chest (preserve dignity and warmth).
Look for:
Symmetrical chest expansion.
Signs of respiratory distress: accessory muscle use, tracheal deviation, flail chest, bruising, wounds.
Cyanosis.
Open wounds
- Assess Respiratory Rate
Normal rate: 12–20 breaths per minute.
Tachypnoea: early sign of distress.
Bradypnoea: late or pre-arrest sign. - Palpate the Chest Wall
Feel for:
Chest wall tenderness (suggests rib fractures).
Crepitus (subcutaneous emphysema — may indicate pneumothorax).
Tracheal position (tracheal deviation suggests tension pneumothorax). - Percuss the Chest
Hyper-resonance: suggests pneumothorax.
Dullness: suggests haemothorax or lung contusion. - Auscultate the Chest
Listen for:
Equal air entry bilaterally.
Decreased or absent breath sounds (pneumothorax, haemothorax).
Added sounds (crackles — pulmonary contusion, wheeze — bronchospasm).
- Provide Oxygen
High-flow 100% oxygen via a non-rebreather mask immediately.
Monitor oxygen saturations — aim for >94% (unless COPD known — tailor target accordingly).
- Intervene Early if Needed
Critical injuries identified at Breathing (6 immediately life-threatening causes):
Tension pneumothorax → Immediate needle decompression then chest drain.
Open pneumothorax → Three-sided occlusive dressing, then chest drain.
Massive haemothorax → Chest drain; consider thoracotomy if massive output. (immediate output of 1.5L, ongoing output of 200ml for 2 hours, ongoing hypovolaemia despite reuscitation)
Flail chest → High-flow O₂; consider intubation if ventilation inadequate.
Pulmonary contusion → Supportive: O₂, fluid careful balance.
Cardiac tamponade → Pericardiocentesis (though mostly found at Circulation step).
- Request Chest Imaging Early
Portable chest X-ray often done during or immediately after B assessment.
FAST scan (part of primary survey) to look for pericardial effusion if trauma suspected.
Circulation management
- Initial assessment (“Look, Feel, Listen”)
Look:
External bleeding.
Skin color: pallor, cyanosis, mottling.
Obvious signs of shock (cold peripheries, delayed capillary refill >2 seconds).
Feel:
Central and peripheral pulses: rate, rhythm, character (e.g., thready pulse).
Capillary refill time: press on sternum or fingertip.
Listen:
Heart sounds (if audible), muffled sounds may suggest tamponade.
- Recognize Shock Early
Hypotension (SBP <90 mmHg) → late sign of hypovolaemia.
Tachycardia → early sign.
Low urine output (<0.5 mL/kg/h).
Confusion or reduced GCS (early shock indicator).
Always assume haemorrhagic shock until proven otherwise in trauma!
- Immediate Actions (“Control and Restore”)
✅ Control External Bleeding
Direct pressure.
Tourniquets for limb bleeding if pressure fails.
Haemostatic dressings if needed.
✅ Secure Large Bore IV Access
2 x wide-bore (14G or 16G) cannulas, ideally into uninjured veins.
IO access (intraosseous) if peripheral IV impossible.
✅ Send Bloods
FBC, U&E, crossmatch at least 4–6 units, lactate, clotting, blood gas.
✅ Begin Fluid Resuscitation
Initially warm crystalloid (e.g., 1L Hartmann’s).
If no response after 1–2L → massive transfusion protocol (MTP) with blood products.
✅ Blood Over Crystalloids If Needed
Early use of O-negative blood or crossmatched.
Major haemorrhage protocols: aim for a 1:1:1 ratio (RBC : FFP : Platelets).
FAST scan
- Identify and Treat Causes of Shock
The 5 life-threatening causes (“on your ATLS mind”):
Tension pneumothorax
Cardiac tamponade
Massive haemothorax
Open pneumothorax
Massive external or internal haemorrhage (e.g., pelvis, abdomen, long bones)
Treat immediately as they are found.
- Monitoring Circulation Response
Vital signs.
Urine output (>0.5mL/kg/hour target).
Lactate clearance.
Mental status (GCS improving).
- Special Interventions
If hypotension persists despite fluids:
Start vasopressors (e.g., noradrenaline) ONLY after adequate volume resuscitation.
Surgical intervention (e.g., laparotomy, thoracotomy) for ongoing bleeding.
classes of haemorrhagic shock
Class1
- blood loss of <750ml (<15% of blood volume)
- no tachycardia, normal BP, RR 14-20, UO >30ml, normal mental state, normal BE.
- no blood products needed
Class2
- Blood loss of 750-1500ml (15-130% blood volume)
- tachycardia >100, normal BP mild;y raised RR 20-30 UO 20-30
anxious
mildly raised BE -2 to -6
possiblity for blood products
Class3
- blood loss of 1500 - 2000ml (30-40% blood volume)
- tachycardia, low BP, raised RR, UO 5-15ml, confused, raised BE -6 to -10
- need blood products
Class4
- blood loss >2L (>40% blood volume)
tachycardia >140, low BP, high rr, no urine output, lethargic, BE -10 or less
- massive transfusion
management of a liver tear
conservative: monitor haemodynamic status, withhold anticoagulation
surgical:
damage control - perihepatic packing (morrisons pouch)
repair
resection
grades of liver tear
american association for surgery of trauma (AAST) guidelines
rates from 1 (minor injury) to 6 (fatal avulsion)
based on CT or intraoperative findings
1 - subcapsular haematoma <10% surface area or a <1cm depth capsular tear
2 - subcapsular haematoma 10-50% surface area, intraparenchymal haematoma <10cm, capsular tear <10cm depth, 1-3cm length
3 - subcapsular haematoma >50% surface area, intraparenchymal haematoma >10cm/expanding pr a capsular tear >3cm deep
4 - laceration involving up to 75% of a lobe or 1-3 segments
5 - lacerarion >75% of a lobe or >3 segments (in one lobe or venpous injury
6 - hepatic avulsion
Haemodynamically stable blunt liver injury
haemodynamically stable blunt liver injjury is best managed conservatively
this includes:
Admission to a monitored trauma bed or ICU.
Strict haemodynamic observation and serial abdominal exams.
Holding anticoagulation and correcting any coagulopathy.
Targeting a transfusion threshold of Hb >80 g/L.
Analgesia while avoiding over-sedation.
Repeat imaging if clinical status changes.
Early involvement of trauma surgery and interventional radiology teams if needed.
Ensuring secondary and tertiary surveys are completed to identify other injuries.**”
IF you aremonitoring a patient with a liver injury and they become unstable what are your options
Urgent interventional radiology embolisation if available.
Otherwise, emergency laparotomy with perihepatic packing (damage control surgery).
Insertion of abdominal drains after packing to monitor ongoing bleeding
Direct repair of accessible bleeding vessels.
Debridement of non-viable liver tissue.
Major liver resection (eg. lobectomy) would be a last resort, usually delayed until physiological stabilisation.
Planned second-look laparotomy within 24–48 hours.
