Principals Flashcards
Discuss A of the primary survey
Airway assessment to decide if securing is required
Is there adeqaute protection
- GCS >= 8
- Sufficient respiratory effort
- No active vomiting
- no significant oropharyngeal bleeding
Then o2 as needed
If no is airway obstruction present –> remove if able
If not intubate –> if not supraglottic if not optimise with (video laryngoscope, different provider) –> surgical airway
Most patient will not have a clear c-spine if intabation is required so manual in-line stabilization should be applied
Discuss B of the primary survey
Is breathing and ventilation adequate If no Is there respiratory distress If No -Consider empirical narcan -Consider emperical glucose -Identify and treat non traumatic causes of hypoxia and hypoventilation
If yes are bilateral breath sounds present Yes -Flail chest -cardiac injury -pulmonary contusion NO (ICC( -tension pneumo -open pneumo -massive haemothorax
Discuss C of the primary survey
Circulation assessment and hemorrhage control
Is the patient shocked
What is the cause
Nonhaemorrhagic
- tension
- cardiac tamponade
- cardiogenic
- neurogenic
- septic
Traumatic
- hypovolaemic (blood or fluid loss)
Should use TXA if whithin 3 horus of trauma, 1 hour is superior
If not using rotem guided 1:1:1 ratio
Discuss indication for the presence of a surgeon in trauma in the ED
A surgeon should be present in the emergency department on trauma patient arrival within 15 minutes if any of the following major criteria are found
-Confirmed hypotension (systolic blood pressure <90)
–Gunshot wounds ot the neck chest abdomen or proximal extremiets
–Intubated patient at scene
Respiratory compromise requiring an emergent airway
-GCS 8
Discuss decision to transport patient to a trauma centre in the prehospital setting
Distance from trauma centre – if very close almost everythign will go to trauma centre, if very far most will go to closer centre for stabilisation prior to transfer
Vitals
- GCS <13
- Systolic <90
- RR <10 or>29 or need for ventilatory support
Anatomy
- Alol penetrating injuries to head, neck, torso and extremities proximal to elbow or knee
- chest wall instability or deformity (e.g flail chest)
- two or more proximal long bone fracture
- crushed or degloved mangled or pulseless extremity
- amputation proximal to wrist or ankle
- pelvic fractures
- open or depressed skull fracture
- paralysis
Mechanism
-Falls
–Adults >20 feet (two storys)
–Chilren >10 feet
High risk auto crush
-intrusion >12 inches at occupant site >18 inches any site
-ejection
-death in same passenger compartment
-vehcile telemtry data consistent with high risk of injury
Auto vs pedestrian/bicyclist thorwn, run over or with significant injury (>30km/hr)
Motocycle crash >30 km/hr
Special patient
Older adults
-risk of death increases after 55 years of age
-SPB <110 might repesent shock older than 65
-low impact mechanisms might result in severe injury
Children
-shoudl be triaged preferentially to paediatic capable facilty
Anticoagulation and bleeding disorder
-patient with head injury are at high risk fo rapid deterioation
Burns
Pregnancy >20 weeks
Discuss low volume resuscitation
Concept remains controversial and is primarily applicable to penetrating trauma
Need to have access to definitive treatment via surgical intervention
Should be treating with blood rather than crystaloid 1:1:1 or ROTEM guided
Allow SBP to fall low enough to avoid exsanguination but keep high enough to maintain perfusion
-MAP not less than 50
Goal is to avoid disruption of unstable physiolgocial clot by higher pressure and worsening of bleeding
-Avoid cyclical resuscitation that can lead to rebleeding and paradoxically exacerbate hypotension
-Once definitive treatment is acheived normal HD is appropriate
End points should be adequate tissue perfusion with normal mentation and normailisation of tissue oxygenation
Contraindications
- head injury
- children
- pregnancy
- delayed access to definitive care >2 hours
Discuss problems with permissive hypotensive approach in australia
Peripheral setting in australia are often long distances and access to definitive care can be delayed
Must not miss non haemorrhagic causes of schock
approrpaite BP can vary in pateint with chornic hypertension
Look at LIFT for evidence should probs know
Discuss post resuscitation cares (ANZCOR)
Prevent further cardiac arrest
-frequent reassessment of ABCD
A: ensure patent and in correct position
B: lung protective ventilation - spo2 94-98% in general
-Paco2 within in normal range and low normal for head injury
C
#HD goals – depending on injury
-penetrating trauma –> permissive resuscitation
-head injury aim for raised MAP >80
-MAP >65 generally
-May be reasonable to continue an infusion of an antiarrhythmic drug that successfully resorted a stable rhythm during resus
D:
-maintain euclycaemia under 10 but avoid hypoglycaeamia
Discuss blast injury classification
Primary
- The direct effects of the blast wave passing through media of different density such as air to tissue.
- Characteristically this affect gas containing organs such as the eardrums lungs and less commonly bowel
- Blast lung is the most common cause of primary blast injury death
Secondary
- Caused by the impact of airborne debris because of blast wind.
- Injuries may be caused by primary fragment (those that are integral to the bomb device) or be secondary fragments (those that come from the environment
Tertiary
- Caused by displacement of the whole body
- it can be the result from either structural collapse or displacement fo the whole body by the blast wind and can typically manifest as blunt or crush injuries depending on the setting
Quaternary
- Include most other blast effects not categorized by primary to tertiary
- These include burns radiation, exposures, inhalation injury, asphyxia, crush injuries, angina, hypertension, psychological consequnce
Describe Pattern of injury to lung and abdo from Blast injury
TM affected at 5PSI
Other organ injury 55-75 PSI
Lung -second most susceptible organ to blast injury
- Pulmonary contusion (butterfly pattern on CXR)
- pneumothoax
- haemothorax
- pneumomediastinum
- subcut air
Abdo injury
- colon most frequently affected
- small intestine less frequently
- mesenteric ischaemic or infarction
- injury to liver spleen and kidney occur with very high blast forces
Eye
-up to 25% of blast survivors have injury to the eye
Brain
- Injury may be a combination of
- –contusions
- –SDH
- –DAI
- –Psychological effected
Describe Crush syndrome
Complex electrolyte disturbance, metabolic acidosis and rhabdomyolosis resulting from crush injury
Features
- Hyperkalaemai, hyperphosphatemia and hyperuricemia from cellular damage
- lactic acidosis from hypoperfusion
- elevated CK and myoglobin
Complications
- compartment syndrome
- arrythmias
- ARFfrom rhabdo
- Vascular compromise
Discuss management of crush syndrome
- Fluid resus to target urine output of 1-2ml/kg/hr
- Aggressively treat hyperkalaemia - calcium administration may lead to metastatic calcification in the presence of hyperphosphatemia
- treat asscoaited injuries including fractures/dislocation, wounds, neurovascular injuries and compartment syndrome
Consider urinary alkinisation with sodium bicarb unproven
