Trauma

Question 1

What is the immediate management of major polytrauma?

Answer 1

ATLS approach:
C-ABCDE:
Catastrophic haemorrhage control
Airway with c-spine control - RSI and MILS with bougie
B: Life threatening chest injuries, TOMFC (tension PTX, open PTX, massive haemothorax, flail chest, cardiac tamponade)
C: IV access, permissive hypotension, activate massive transfusion protocol, consider REBOA, level one rapid infusor, avoid crystalloids, damage control surgery.
D: TBI management
E: avoid hypothermia, top to toe examination.

Question 2

How do you classify haemorrhagic shock?

Answer 2

ATLS classification (8 parameters, classed 1 to 4):

• % circulating volume lost: <15%, 15-30%, 30-40%, >40%
• Blood loss (ml): 750, 750-1500, 1500-2000, >2000
• SBP: normal, normal, low, very low
• DBP: normal, increased, low, very low
• HR: <100, 100-120, 120-140, >140
• RR: 14-20, 20-30, 30-40, 30-40
• UO (ml/hr): >30, 20-30, 10-20, 0
• Mental state: alert, anxious/aggressive, confused, drowsy/unconscious

Question 3

What scoring systems can you use for assessing injury severity?

Answer 3

Injury severity score (ISS) uses the abbreviated injury scale (AIS) to score six body regions.

AIS (6 classifications):

1: minor
2: Moderate
3: serious
4: severe
5: critical
6: maximal (untreatable)

Body regions:

1. Face
2. Head and neck
3. Chest
4. abdomen and pelvis
5. extremities and pelvic girdle
6. external

ISS = A2 + B2 + C2 (A,B and C are the three most injured regions).
Maximal score is 75
Severe trauma is greater than or equal to 16.

Question 4

What is damage control resuscitation?

Answer 4

Preservation of effective clotting and tissue perfusion in a patient with uncontrolled haemorrhage to buy time until anatomical haemorrhage control has been achieved.

4 pillars:

1. Early administration of blood products
2. Permissive hypotension
3. Prevention and correction of coagulopathy
4. Expedited damage control surgery

Question 5

What ratio of blood products should be used in damage control resuscitation?

Answer 5

PROMMTT study found early use of plasma and platelets improved 6-hour survival.
PROPPR trial compared FFP, platelets and RBC ratio of 1:1:1 vs 1:1:2 and found 1:1:1 achieved better haemostasis and less death due to exsanguination.

Question 6

What is permissive hypotension?

Answer 6

Permissive hypotension is the targeting of SBP 80-90 or MAP 50-65 with small volume blood products until haemorrhage control is achieved.
Aggressive fluid resuscitation promotes extravasation and clot displacement.
There is evidence that supports improved survival and less post-operative coagulopathy in permissive hypotension.

Question 7

What is coagulopathy of trauma and how is it treated?

Answer 7

One of the three components of the triad of death.
Coagulopathy confers a four-fold increase in mortality.
Pathophysiology includes systemic activation of protein C pathway and generation of activated protein C (inhibits factors V and VIII and decreases fibrinogen utilisation) leading to reduced thrombin generation and increased fibrinolysis.

Four main factors worsen trauma-induced coagulopathy:

1. DIC
2. Dilutional coagulopathy
3. Hypothermia
4. Acidosis

Question 8

What is the role of TXA in major trauma?

Answer 8

CRASH-2 trial demonstrated survival benefit if TXA given in first 3 hours.
CRASH-3 demonstrated reduced mortality in extra cranial injury TBIs without increase in mortality in other TBI groups.

Question 9

How would you guide blood product transfusion in major trauma?

Answer 9

Urgent bedside tests are useful, but in major trauma haemorrhage, transfusion should be guided by clinical parameters and later guided by laboratory and bedside tests such as:

• FBC
• ABG
• viscoelastic haemostatic assays (TEG and ROTEM) - however ITACTIC trial did not find an outcome benefit over conventional coagulation tests.