SCBD (Resus)

Question 1

RESUSCITATION TEMPLATE:

Answer 1

The key issues here are:
eg. life threatening haemorrhage, undifferentiated shock, agitation interfering with management etc.

I would call for assistance with the emergency bell

I would keep in/ transfer to resus cubicle (and apply full physiological monitoring incl end tidal CO2)

I would designate myself team leader and assemble a team and assign roles that include: a,b,c.

Check adequacy of existing Mx
–> (CPR, PBI, pelvic binder etc.)

This is a resus where A NUMBER OF ACTIONS OCCUR CONCURRENTLY.

I would remain hands-off as team leader

A
I would have them positioned them upright/ lie/ ramp.

If there was any evidence of airway compromise such as snoring or stridor, I would ask for a chin lift, jaw thrust manouevre and a nasopharyngeal airway.

There is an immediate/ anticipated airway threat here so I would have anaesthetics called for support ….whilst setting up for intubation.

B
I would apply 100% FiO2 at 15L via non-rebreather mask with a target SpO2 of 88-92%/ 92%/ 94%.

If respiratory efforts were inadequate, I would ask for bag ventilation at 20bpm whilst preparing for NIV/ intubation.

C
I would ask for dual large bore IV access. If cannulas not successful within X, for tibial/humeral IO under local.

20ml/kg (1L) resus bolus of normal saline. If inadequate haemodynamic response following that, initiate vasopressors.
My choice would be noradrenaline at 0.1microg/kg/minute, with early targets of SBP 90/ MAP >65 (80 in neuro)/improvement in conscious state*
OR
Early transfusion with warmed, O negative packed red cells (10ml/kg paeds)….etc.

D
Seek & treat:
- Seizure, hypoglycaemia, major electrolyte

Specific early Tx:
–> Lysis, DCR, antidote.

Referral & disposition
–> incl. imaging/ OT/ ICU, retrieval, palliation

Question 2

FELS (shock, arrest):

Answer 2

I would perform a focused bedside echo, looking for:

Absence of ling sliding

Pericardial effusion and, if present, tamponade physiology
(diastolic RV collapse, systolic RA collapse and plethoric IVC, with <50% inspiratory collapse)

Global LV function
*(LV walls coming two thirds of the way together.)

RV strain
(Dilated RV, flattened IV septum, McConnell’s sign, IVC plethora- >2cm/<50%)

IVC collapsibility as marker of volume

Question 3

eFAST:

Answer 3

Given this is a hypotensive trauma patient, I would perform an eFAST ultrasound.

Using a curvilinear probe,

I’d look at RUQ for presence of fluid in Morrison’s pouch, or evidence of R sided pleural effusion

LUQ for fluid in the splenorenal angle or under the diaphragm and L sided pleural effusion

Pelvis in longitudinal and transverse suprapubic views looking for presence of fluid in pouch of douglas/ rectovesical space

and on the lung apices for absence of lung sliding.

*** If negative, I would repeat the eFAST at regular intervals

Question 4

Preparation for EO caesar:

Answer 4

Obstetric Code

Intubate if E0

Consider Anti-D
Blood group & hold

NGT and stomach decompression
IDC

Question 5

Haemostatic Resuscitation: process

Answer 5

Position
Control active bleed

Dual large access
Conservative temporising fluid bolus (eg. 10ml/kg)
Early Blood:
- MTP if >6 units anticipated
- O neg
- Warmed, via pressure bag/ rapid infuser

Correct coagulopathy:
- eg. FFP 4 units, cryo 4 units , prothrombinex 25-50units/kg, recombinant factor, Vit K 10mg IV, DDAVP, TXA.

Triad
- Warm
- Ionised Ca > 1.1
- Correct acidosis to pH >7.1

Frequent bloods
Seek and Tx hyperK
Liase Haematology
Art line

Question 6

Haemostatic Resuscitation: targets

Answer 6

Hb > 70/100
Plts >50
APPT/PT <1.5x normal
INR <1.5
Fibrinogen >1
Ion Ca > 1.1
pH >7.1

Question 7

Haemodynamic/ shock targets:

Answer 7

SBP >90
MAP >65 (80 SCI)
PR < 100
Cap refill <4

Lactate <2 (20% clearance 2hrs)
Urine output >0.5ml/kg/hr (1 kids, 2 infants)

Better mental state
Improved pulses
Decreasing pressor requirement