Trauma

Question 1

What size cannula is used for needle thoracostomy in adults? Pediatrics?

Answer 1

Adults -10g x 8cm ARS Needle
Decompression Kit
Pediatrics (< 13yrs) - 14g x 5cm InSyte Cannula

Question 2

What are the indications for needle thoracostomy?

Answer 2

• Traumatic cardiac arrest (with torso
  involvement).
• Suspected pneumothorax with significant
  respiratory or haemodynamic
  compromise

Cardiovascular compromise may be a late sign,
often preceded by respiratory failure and
hypoxia.

Question 3

What are the signs of a tension pneumothorax?

Answer 3

Tension pneumothorax should be considered in
a patient with significant trauma, who is
exhibiting signs of severe respiratory distress,
diminished unilateral lung sounds, hypoxia
and/or shock.
Signs such as jugular venous distension, tracheal deviation or subcutaneous emphysema may be difficult to observe and are unreliable indicators of tension pneumothorax

Question 4

What sites may be considered for needle decompression?

Answer 4

Primary location: 2nd intercostal space, mid-clavicular line
Alternatively (if above not practical), can use 4th or 5th intercostal space, anterior to mid-axilla line.

Question 5

When should needle decompression be performed in the axilla?
Can this alternative site be used in pediatrics?

Answer 5

Alternative location to be used in patients where
* CPR is being conducted or expected to
be conducted (e.g. traumatic OHCA)
* Anatomical landmarks of the anterior
chest are unidentifiable or inaccessible
* Gross deformity or skin infection over the
anterior chest wall

Locating the correct landmarks at 4/5AAL
requires abduction of the arm to 90°. Therefore,
this site is only practical for patients outside of
the ambulance.

In pediatrics, ICP skill only.

Question 6

In tension pneumothorax, what is the location for secondary/subsequent needle decompression(s) if the first catheter fails?

Answer 6

If catheter failure is suspected (i.e. catheter blocked) and/or if clinical deterioration suggests redevelopment of tension symptoms, reswab, allow to dry and insert another needle-catheter, approximately 1cm lateral to the previously inserted catheter.

Question 7

What size syringe is placed at the end of the NT cannula? How much fluid should be in the syringe?

Answer 7

10ml Luer-lok syringe
2-4ml saline in syringe.

Question 8

How is correct placement of the cannula confirmed in a NT?

Answer 8

Advance needle/cannula until initial resistance overcome.
Draw back on syringe - bubble in fluid confirms correct placement into the pleural space.
If no bubbles, advance needle/cannula 1-2cm and reattempt aspiration.

Question 9

What is the process of identifying the site of NT in the axilla?

Answer 9

• Adduct arm and bend elbow to 90deg
• Measure acromium to elbow with tape
• Fold tape in half to find midpoint of humerus (from acromium)
• Find point on axilla where midpoint of humerus projects onto axilla - place finger
• Abduct arm to 90deg- finger location now indicates point of decompression

Question 10

What is the guideline for managment of an amputated part?

Answer 10

Seal body part in water-tight bag.
Place bag in ice-cooled water if possible.
Body part should not be in direct contact with ice.

Question 11

When is an arterial tourniquet indicated?

Answer 11

Life-threatening haemorrhage not controlled by direct pressure.

Question 12

What are the 3 “dont’s” of arterial tourniquets?

Answer 12

Don’t
* Place over a joint or wound
* Cover with clothing
* Remove in the field

Question 13

When should clinical support be called in burns?

Answer 13

Significant burns
Airway burns
Uncontrolled pain

Question 14

What is the treatment in suspected airway burns?

Answer 14

In airway burns, airway managment and urgent transport take priority over cooling.

Treatment:
* Universal care
* Request Clinical support
* Consult EOC clinician
* Rapid transport with notification

Question 15

How long should thermal burns be cooled with running water in adults? Pediatrics? Neonates?

Answer 15

All 20 min.

Question 16

If water is not available, how long should thermal burns be cooled with hydrogels in adults? Pediatrics? Neonates?

Answer 16

Adults and pediatrics - 20 min.
Neonates - max 10min

Question 17

When is fluid indicated in burns patients? How much is given?

Answer 17

Indicated for burns patients with signs of poor central perfusion.
All patients - 10ml/kg (max 250ml) aliquots up to 20ml/kg
In pediatrics we’re targeting lower range of normal SBP for age.

Clinical consult if fluid > 20ml/kg required

Question 18

In which patients should pulmonary contusion be suspected?

Answer 18

Chest trauma patients who are hypoxic without obvious cause.

Most common thoracic injury in children due to the elastic properties of the paediatric ribcage and may occur in the absence of obvious chest wall injury

Question 19

In severe haemorrhage, what are the components of the lethal triad?

Answer 19

Coagulopathy - Catastrophic haemorrhage can lead to extensive loss of clotting factors as well as accelerated consumption of clotting factors and excessive clot breakdown (hyperfibrinolysis). Haemodilution can increase coagulopathy by diluting clotting factors.

Acidosis causes multiple negative impacts on the clotting cascade and coagulation

Hypothermia impacts coagulation by reducing platelet function as well as reducing the activity of clotting cascade enzymes

Question 20

What are the principles of damage control resuscitation?

Answer 20

• Haemorrhage control
• Temperature management
• Movement minimisation
• Access to early blood product administration (TXA)
• Targeted fluid resuscitation
• Rapid transport to definitive care

Question 21

In damage control resuscitation, when should fluid be administered? What is the target / fluid endpoint?

Answer 21

Fluids indicated when pt has inappropriate response to verbal commands.
Administer 10 mL/kg aliquots (max 250 mL) up to 20 mL/kg.

Target - minimum fluid to retain alertness such that patient responds to verbal commands.
If pt unresponsive for other reasons, target radial pulse.

Question 22

Considering damage control resuscitation, in which patients is permissive hypotension not appropriate?

Answer 22

Permissive hypotension not appropriate for patients with suspected traumatic brain injury - TBI takes priority over damage control resuscitation.

Question 23

Which trauma patients may receive TXA?

Answer 23

Patients with blunt or penetrating trauma.
Consider IV TXA 1 g bolus slow push over 2 - 3 mins if:
* ≥ 16 yrs and
* < 3 hrs of injury and
* HR > 120 and/or SBP < 90 mmHg