TARMS

Question 1

When do deaths from trauma occur?

Answer 1

In a TRIMODAL distribution:

• At time of injury (seconds to minutes)
• Minutes to hours post injury
• Day to weeks post injury

Question 2

How do we assess the severity of trauma?

Answer 2

With TRAUMA SCORES
ISS (injury severity score) most commonly used, others include AIS (abbreviated injury score), RTS (revised trauma score)

Question 3

How should you initially assess a patient with trauma?

Answer 3

ABCDE (broken leg isn’t going to kill them before an obstructed airway does)
DOCUMENT TRAUMA OBSERVATION UNDER E
Then assess properly with thorough trauma assessment

Question 4

What extra considerations should you have when assessing an airway of a trauma patient?

Answer 4

ALL NORMAL THINGS (stridor, obtundation, snoring, trachea central, paradoxical movements)
+
Facial injuries/burns
Neck wounds
Epistaxis or vomiting
Head injury leading to low GCS (GCs<8 intubate)
C-SPINE INJURY - might impact airway manoeuvres

Question 5

When assessing breathing, what are some injuries that could compromise ventilation?

Answer 5

Summarised by ATOM FC

• Airway obstruction
• Tension pneumothorax
• Open chest wound
• Massive haemothorax (>1500mL)
• Flail chest (2 or more ribs broken in 2 or more places - indicates high force injury)
• Cardiac tamponade

Question 6

When assessing circulation in trauma what should we be assessing/looking for and what are some common types?

Answer 6

Main concern is SHOCK:

• Assess pulse (rate rhythm character),
• Blood pressure
• Heart rate
• CRT (peripherally and centrally)
• Skin temperature
• Urine output / consciousness level

CAUSES OF SHOCK IN TRAUMA
- Haemorrhagic, Cardiogenic, Neurogenic, Obstructive

Question 7

What is the most common form of shock in trauma and where can volume commonly be lost?

Answer 7

Hypovolaemic (haemorrhagic). Blood loss commonly described as being OCCULT (meaning hard to discern).
Mantra ‘one on the floor and four more is often used to reflect the fact that blood is commonly lost into potential spaces in the body making it hard to identify:
CHEST, ABDO, PELVIS and LONG BONES (esp femur)

Question 8

If you suspect someone is loosing a lot of blood and is shock how should they be initially managed?

Answer 8

Optimise oxygenation
Splints/tourniquets/direct pressure for active haemorrhage
2x Wide-Bore Cannulas into each ACF (get cross match for 10U)
Fluid Resus - Crystalloid (warmed) or Blood (O- until cross match is back)
IV TRANEXAMIC ACID if active haemorrhage
MASSIVE TRANSFUSION PROTOCOL

Question 9

How does TXA work?

Answer 9

Tranexaminc acid binds to lysine receptors on plasminogen which prevents plasmin from being used and degrading fibrin (encourages clots to be made)

Question 10

What does the massive transfusion protocol include?

Answer 10

4 units red cells 4 units FFP
Can give O- blood if waiting for cross match but group specific blood should be given as soon as possible because O- is scarce resource
Also always give TXA

Question 11

What should be included on your disability assessment for a trauma patient?

Answer 11

A thorough assessment for any head trauma is necessary
GCS, Pupil response (important for head injury)
ALWAYS GET GLUCOSE HERE

Question 12

Where is the most common area of the spine to be affected in trauma?

Answer 12

Cervical region (55%)

Question 13

What kinds of things can cause secondary injury to the spine?

Answer 13

Hypoxia, hypotension, hypoglycaemia or mechanical disturbances due to inappropriate moving or positioning

Question 14

What are the four main types of spinal cord injury to be aware of?

Answer 14

Anterior cord syndrome
Central cord syndrome
Brown-Sequard Syndrome
Complete spinal cord syndrome

Question 15

How does anterior cord syndrome present?

Answer 15

Causes by damage to motor and sensory areas in the anterior cord
Presents as loss of movement and sensation

Question 16

How does central cord syndrome present? Who is it more common in?

Answer 16

Most common in OLDER PEOPLE who slip and fall
Affects the CORTICOSPINAL TRACT (carries movement fibres)
Loss of movement and paralysis (much worse in arms than legs) - often can still walk but struggle with arm movement

Question 17

How does Brown-Sequard syndrome present?

Answer 17

ONE SIDE OF THE SPINAL CORD - most commonly seen after knife injury or sometimes when tumour compresses one half
Lose motor function in one side of body (ipsilateral)
Lose sensory function in one side of body (contralateral)
***this is because fibres in the spinothalamic tract decussate at the level of the spinal cord whereas dorsal column fibres cross over at the pyramid level

Question 18

How do we assess whether someone might have a C-Spine injury?

Answer 18

Using the CANADIAN C-SPINE RULE
HIGH RISK IF:
- over 65, Dangerous mechanism of injury (falling more than 1m or 5 stairs) or fall onto head, parasthesia in upper or lower limbs
LOW RISK FACTORS:
- Minor rear-end RTA, Comfortable sitting, ambulatory at any time since injury, no midline cervical tenderness, delayed onset of neck pain
NO RISK:
- if they have low risk factors BUT are able to rotate their head through 45 degrees to the L and Right

Question 19

How should a patient with a suspected spinal injury be managed?

Answer 19

Optimise oxygenation 
Prevent blood pressure drops to maintain perfusion to spinal cord 
Immobilise 
Urinary catheter 
Definitive imagining 
Early specialist advice

Question 20

What are the three factors of the trauma triad of death?

Answer 20

Coagulopathy, hypothermia and metabolic acidosis

Question 21

Explain how the three aspects of the trauma triad of death feed into one another

Answer 21

HYPOTHERMIA LEADS TO COAGULOPATHY
- Imbalance between thromboxane and prostacyclin meaning clotting cascade not as efficient. This is why it is essential to warm a patient during trauma care (blood products and fluid resuscitations should also be warmed)

COAGULOPATHY LEADS TO METABOLIC ACIDOSIS
Poor distribution of blood means ischaemic tissues and hypoxia leading to lactic acidosis. Acidaemia reduces cardiac output, exacerbating the shocked state and causing right shift to oxygen dissociation curve

METABOLIC ACIDOSIS LEADS TO HYPOTHERMIA
Poor CO means less perfusion and worsening hypothermia

Question 22

How are pelvic fractures managed?

Answer 22

Pelvic binders commonly placed pre-hospital (prevents movement of pelvis and hopefully encourages stasis of any blood loss)

Question 23

What is an emergency complication of bone fractures?

Answer 23

COMPARTMENT SYNDROME
Pressure builds up in muscular compartment - sometimes pressure builds up so high that it can occlude blood vessels leading to death of the limb
- FASCIOTOMY needed to treat