81. Trauma

Question 1

You are called to casualty to assess a 25-year-old male pedestrian who
has been hit by a car at unknown speed. He was unconscious at the
scene and has an obvious compound fracture of his right tibia and fibula.
His foot is cool and dusky. He is agitated and his GCS is now 14. The
orthopaedic surgeons want to fix his leg as soon as possible.
How would you assess this patient?

Answer 1

This is a major trauma case and he should be assessed and resuscitated
according to the ATLS guidelines. From the history he may have sustained
occult life-threatening injuries such as a fractured pelvis, intra-abdominal or
intra-cerebral haemorrhage.

Question 2

Assessment

Answer 2

1. Airway and cervical spine
   Look for evidence of airway obstruction, especially facial fractures and foreign bodies in the mouth.
2. Breathing
   Expose the chest and examine for adequacy of ventilation:
   Inspection, palpation, percussion, auscultation
   Measure SaO2 and respiratory rate.

Beware at this point:
Tension pneumothorax
Flail chest
Open pneumothorax
Massive haemothorax.

Question 3

CDE

Answer 3

Circulation
Skin colour and capillary refill
Pulse, ECG
Blood pressure
Level of consciousness
This patient is likely to have sustained a head injury. It is therefore vital to
maintain mean arterial pressure in order to optimize cerebral perfusion pressure

Dysfunction
AVPU
GCS

Exposure
To complete the primary survey

Question 4

Steps

Answer 4

After a thorough assessment of his injuries in casualty, it is important to
prioritise his further management, e.g. potential life-threatening
haemorrhage from his abdomen takes precedence over a potential head
injury.

Question 5

What investigations would you like before taking him to theatre?

Answer 5

Cervical spine, chest and pelvis X-rays.

Haemoglobin and cross-match, urea, electrolytes and glucose.

If there is any cardiovascular instability with no obvious cause or there are
positive abdominal signs, then further investigation of the abdomen is
indicated. This may take the form of FAST ultrasound or CT scan.

A general surgeon should be present from the outset as part of the trauma team.

In view of the history, a CT scan of his head is indicated to exclude
intracranial pathology such as haemorrhage or oedema.

Question 6

The patient is too agitated to tolerate a CT scan. How would you
manage this situation?

Answer 6

This patient now requires a general anaesthetic for his CT scan. (He also needs
an anaesthetic for his tibia and fibula fracture. Although a regional technique
would be ideal for his lower limb surgery, it is not practical because of his
agitation. A central neuroaxial block may also have detrimental effects on
cerebral blood flow due to the fall in mean arterial pressure.

In addition to this, there is the theoretical risk of coning associated with dural puncture.)

He should be anaesthetised in casualty with a rapid sequence induction and
intubation with C-spine immobilisation (either by hard collar or manual in-line
stabilisation).

It is important to pay careful attention to measures that help
prevent a rise in intracranial pressure (see question on raised intracranial
pressure).

If there is vascular compromise in the leg, then manipulation and
temporary stabilisation could be performed after the patient has been
anaesthetised and is being prepared for transfer to the CT scanner.

The further management of the fracture will depend on the result of the CT
scan and whether any other life-threatening injuries require treating first