Trauma

Question 1

How do you manage a severe open limb fracture?

Answer 1

A-E assemsment
BOAST 4
Give IV antibiotics as soon as possible - co amoxiclav 1.2g every 8 hours, consider tetanus status
Continually assess neurovascular status of the limb
Immediate surgery if vascular impairment or compartment syndrome
Urgent surgery if the wound is heavily contaminated e.g. sewage
Debridement by a combined plastics and orthopaedics within 24 hours
Cover wound with saline soaked gause to prevent desiccation
Splint the limb

Question 2

What is the number 1 priority when approaching a pre hospital scene?

Answer 2

Your presonal safety - stop traffic, wear PPE etc.

Question 3

How would you handover a patient from the pre hospital environment to the emergency depatment? Practice.

Answer 3

ATMIST
Age
Time of Injury
Mechanism of injury
Injury
Signs - vital signs
Treatment given

Question 4

What are the principles of managing major haemorrhage in A and E?

Answer 4

Early haemostasis with surgery, splintage or angiography
Awareness and treatment of the lethal triad
Avoid excessive crystalloid/colloid use
Give FFP/Red cells/platelets early in 1:1:1 ratio
hypotensive resuscitation

Question 5

Why should crystalloids be avoided in modern day trauma resuscitation?

Answer 5

They dilute the blood and contribute to coagulopathy

They contribute to hypothermia

Question 6

What blood pressure is aimed for in trauma resusitation?

Answer 6

80-90mmHg in penetrating trauma and 90 in blunt trauma

Question 7

What are the 4 main places blood can be lost from in haemorrhage?

Answer 7

Chest - treat haemothorax with chest drain
abdo - may need surgical intervention
Pelvis and long bones - need splinting
cranial haemorhage

Question 8

What is the lethal triad of trauma?

Answer 8

Hypothermia
Coagulopathy
Acidosis

Question 9

How does hypothermia worsen hypoxia?

Answer 9

It dampens the CVS response to hypovolaemic shock so the body cannot cope as well

Question 10

How does acidosis occur and worsen trauma outcomes?

Answer 10

Tissue hypoperfusion causes lactate production and acidosis. This is made worse by hypoventilation from flail chest for example. Changes in pH affect the clotting and cause coagulopathy

Question 11

How can you help to prevent the lethal triad at the scene of trauma?

Answer 11

Search thoroughly for the source of bleeding and apply pressure. Always assume your patient is getting colder so apply warming blankets and warm fluid

Question 12

What is the mneumonic for secondary assessment?

Answer 12

Has my critical care assessed patient’s priorities or next management decision?

• Head/skull
• Maxillofacial
• Cervical spine
• Chest
• Abdo
• Pelvis
• Perineum
• Orifices
• Neurological
• Musculoskeletal
• Diagnostic tests

Question 13

What is the most important initial management for chest injury?

Answer 13

15L O2 in non rebreather mask

Question 14

What are the life threatening chest injuries?

Answer 14

ATOM FC

• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Flail chest
• Cardiac tamponade

Question 15

What is Beck’s triad of cardiac tamponade?

Answer 15

Raising JVP
Decreasing BP
Muffled heart sounds

Question 16

What is the difference between primary and secondary head injury?

Answer 16

Primary head injury is the damage caused by the impact

Secondary is the damage that arises afterwards e.g. raised ICP from swelling

Question 17

How can you minimise secondary brain injury in the prehospital environment?

Answer 17

By optimising ABC to prevent low BP, hypoxia etc.
keep sbp above 90
Mannitol to help reduce ICP
Head at 30 degree to aid venous drainage

Question 18

What are the imaging reccommendations for head injury?

Answer 18

Patients need to recieve a head CT in 1 hr of injury if they have reduced GCS
Note, caution with under 16 as large radiation dose

Question 19

What are some of the presentations that promp urgent CT in head injury?

Answer 19

Lowered GCS
Skull base fracture or depresssed skull fracture
Post trauma fit
Focal CNS signs
Greater than 1 episode of vomiting