Trauma Flashcards
What is the immediate management of major polytrauma?
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.
How do you classify haemorrhagic shock?
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
What scoring systems can you use for assessing injury severity?
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.
What is damage control resuscitation?
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
What ratio of blood products should be used in damage control resuscitation?
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.
What is permissive hypotension?
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.
What is coagulopathy of trauma and how is it treated?
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
What is the role of TXA in major trauma?
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.
How would you guide blood product transfusion in major trauma?
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.
Causes of a left raised hemidiaphragm in trauma?
There are several possible causes for an elevated hemidiaphragm on a chest X-ray. It can
either be ‘pulled up’ from above, ‘pushed up’ from below or be ruptured.
Given the history of severe trauma, the possibility of a possible phrenic nerve injury should
be considered. [1]
Respiratory pathology including atelactasis and rib fractures can result in an elevated
hemidiaphragm. [1]
Abdominal pathology including splenic injury, haematomas and subphrenic collections
should also be considered. [1]
Finally, direct trauma to the diaphragm resulting in a diaphragmatic rupture is an important diagnosis to exclude and can be caused by either blunt or penetrating trauma. Most diaphragmatic injuries are on the left side.
What are the indications for surgical intervention for a haemothorax?
A thoracotomy may be indicated if > 1.5 litres blood drained immediately, there is ongoing
blood loss of 200–250 mL/hour over the next 4 hours or in the presence of haemodynamic
instability
Describe how you will prepare for a chest drain insertion for a traumatic haemothorax?
Patient – Give an explanation and obtain consent. You need adequate intravenous access.
Review the imaging and confirm correct side.
Equipment – You need adequate basic monitoring, and a formal chest drain insertion kit
(scalpel, curved clamp, chest drains of various sizes, underwater seal). A Seldinger drain
is not appropriate in the setting of a haemothorax.
Personnel – You need appropriate trained assistance.
Drugs – You need access to local anaesthesia, analgesia, oxygen if needed.
Identify landmarks – The ‘safe triangle’ describes an area bordered by the lateral border of
the pectoralis major, the anterior border of the latismus dorsi and above the horizontal
level of the nipple and with an apex below the axilla. The 5th intercostal space in the
mid-axillary line is in this safe triangl
Describe how you would manage a trauma patient who is cardiac arrest/periarrest?
- Consider non traumatic causes, if likely, proceed with ALS
- if unlikely start ALS and simultaneously address reversible causes
> Hypoxia
> Tension PTX
> Tamponade
> Hypovolaemia - Control external catastrophic haemorrhage
- Control airway and maximise oxygentation
-Bilateral chest decompression - relieve cardiac tamponade
- surgery for haemorrhage control or proximal aortic compression
- consider resuscitative thoracotomy if unable to achieve ROSC
Describe how the chain of survival for the trauma patient with major haemorrhage?
Prehospital
- limit blood loss, prevent lethal triad (coagulopathy, acidosis, hypoxia), rapid transfer to MTC
MTC
- Primary survey
- Address 5 sites of likely haemorrhage - Long bones, chest, abdomen, pelvis, external
- Stable - imaging and surgical or non surgical management
- unstable - MTP with transfusion 1-1-1
- FAST, CxR, Pelvis Xray if able
- Consider surgical management and or embolisation for damage control resuscitation
