Resuscitation in Major Trauma

Question 1

Ix in trauma case

Answer 1

• Primary assessment
• FAST scan (US in trauma)
• CXR
• ECG monitor
• ABG
• intubation if low GCS
• FBE (lactate - duration of hypoperfusion etc), UEC, CMP, LFT (significant injury to liver), lipase (pancreatic injury), coags (to avoid coagulopathy & need to replace coagulants if bleeding as plasma is also lost), acidosis & hypothermia (don’t clot well)
• IV fluids & analgesia
• mostly CT PAN (head, chest, pelvis)

Question 2

What are Trauma Bloods Ix?

Answer 2

FBE (lactate - duration of hypoperfusion etc), UEC, CMP, LFT (significant injury to liver), lipase (pancreatic injury), coags (to avoid coagulopathy & need to replace coagulants if bleeding as plasma is also lost), acidosis & hypothermia (don’t clot well)

Question 3

Why do you use orogastric tubes in Trauma instead of nasogastric tubes?

Answer 3

Because there may be skull fractures

Question 4

Erect CXR: air fluid levels with no meniscus. What does it indicate?

Answer 4

Haemopneurothorax

But this change is more subtle on a supine CXR. Hence do an US to check.

Question 5

How does tension pneumothorax present on CXR?

Answer 5

• shifted mediastinum
• Trachea pulled away
• No lung markings in the affected area
• hyperexpanded lung

Question 6

What (8) could cause ongoing tachycardia & hypotension in trauma cases?

Answer 6

• Blood loss (e.g. intraabdominal, due to limb injury, cerebral, on the scene; car, road, bed)
• Tamponade (e.g. due to tension pneumothorax
• Neurogenic. brain reflexes due to brain injury, spinal shock
• drugs/alcohol esp in young
• warfarin/beta blockers in elderly (Heart cannot compensate due to beta blocker)
• pain, anxiety
• sepsis (late)
• myocardial contusion

Question 7

How do you first manage pelvic fractures?

Answer 7

Pelvic binder. Compresses bones together to limit venous bleeding

Question 8

How do you manage bleeding (4) in trauma?

Answer 8

• control peripheral bleeding with packs, staples, sutures
• CXR for thoracic blood
• FAST, CT or DPL for abdo blood
• Ensure primary survey is complete. examine limbs & perineum. Log roll for occult injuries (and spinal exam)

Question 9

What fluids do you give in a bleeding trauma pt?

Answer 9

After 2 L of saline/crystalloid -> switch to bloods

Choices of Crystallodis: normal saline, hypertonic saline, Hartmanns
Collodis: Haemacel, Dextran (rarely used), Blood, blood replacements

Question 10

SE of too much Saline (1)

Answer 10

Hyperchloraemic acidosis

Question 11

What choice of colloids do you give in a trauma bleeding pt?

Answer 11

Blood: give early
Blood products: massive transfusion requires platelets, clotting factors, keep pt warm.

1:1:1 (1 bag of FFP, 1 bag of blood product, 1 dose of platelets)

Question 12

What BP is optimal in trauma?

Answer 12

SBP >90
MAP >55

Balance of high BP (more bleeding) vs. low BP (low perfusion)
Depends on the pt’s normal BP as well

Question 13

What injuries could you suspect in a high speed MVA?

Answer 13

Decelerating injury: Aortic dissection
Seat belt injury
C-spine injury