Trauma management

Question 1

What are some common interventions performed in pre-hospital emergency setting?

Answer 1

Low-threshold interventions that may be performed by emergency personnel prior to transport to a hospital include, but are not limited to:

• Placement of a cervical collar (if cervical spine trauma is suspected)
• Intubation or oxygen delivery via nasal cannula (if respiratory distress or altered mental status is suspected)
• Administration of intravenous fluid (if hemorrhage or hypotension is suspected)
• Administration of analgesia
• Placement of tourniquets or pressure bandages for control of bleeding

Question 2

What technique/protocol do we use in primary survey?

Answer 2

Advanced Trauma Life Support (ATLS) -> ABCDE steps performed in order

Question 3

What are components of ‘A’ (ABCDE) ?

Answer 3

Airway assessment

(and cervical spine stabilization)

• If appropriately answering questions ->patient has a patent airway (at least for the moment)
• Observe patient for signs of respiratory distress
• Inspect mouth and larynx for injury or obstruction
• Assume cervical spine injury in blunt trauma patients until proven otherwise
• If patient is unconscious (and therefore unable to protect their airway) or in respiratory distress, the threshold for intubation is very low

Question 4

Do we intubate patients with burns?

Answer 4

Patients with burn injuries + evidence of respiratory involvement -> often intubated out of precaution

Question 5

What to do if orotracheal intubation fail?

Answer 5

Perform cricothyrotomy

Question 6

How to ‘prove’ that there is no C-spine injury?

Answer 6

• no evidence of fracture on cervical x ray
• no signs of tenderness in an otherwise neurologically normal patient

Question 7

Possible signs of respiratory distress (3)

Answer 7

• tachypnoea
• use of accessory muscles
• stridor

Question 8

Components of ‘B’ assessment (ABCDE)

Answer 8

Breathing

• Assess oxygenation status with pulse oximetry
• Inspect and auscultate chest wall for injuries -> absence of breath sounds, asymmetric or abnormal movement

Question 9

Inunstable patient, if we suspect tension pneumothorax/ haemothorax; do we treat first or do we perform imaging to confirm?

Answer 9

In unstable patients, do not delay treatment of tension pneumothorax or hemothorax in favor of imaging.

Question 10

What central pulses do we palpate?

Answer 10

Central pulses

• carotid
• femoral

Question 11

What peripheral pulses do we palpate?

Answer 11

radial, popliteal, posterior tibial, dorsalis pedis

Question 12

Components of ‘C’ (ABCDE)

Answer 12

Circulation

• palpate pulses: central and peripheral
• BP (if possible, but if it cannot be done then just move to the other steps of assessment)
• place IV lines -> intraosseous line if IV placement impossible
• control of haemorrhage -> ongoing pressure or tourniquet placement
• look for signs of hypovolaemic shock

Question 13

What IV lines should be placed in the patient during ‘C’ component? Why?

Answer 13

Place two large-bore intravenous lines (at least 16 gauge) for blood typing and crossmatch, and resuscitation (if needed).

Question 14

How do we control ongoing hemorrhage in prehospital setting?

Answer 14

Manual pressure or tourniquet

Question 15

What do we do if the patient is hypotensive?

Answer 15

Bolous IV saline fluid administration

Question 16

What if we do not know the patient’s blood group and there is an ongoing hemorrhage?

Answer 16

0 type blood transfusion

Question 17

What to do if there are persistent blood loss and hemodynamic instability?

Answer 17

Transfuse: plasma, platelets and RBCs - 1:1:1 ratio

*this also will prevent coagulopathy caused by: trauma and massiv transfusion of blood

Question 18

How much blood is required to be lost in order for the hypovolaemic shock to occur?

Answer 18

at least 1.5 L

*but haemorrhage may be both: internal and external

Question 19

What are the components of ‘D’ (ABCDE)?

Answer 19

Disability

• GCS
• pupil size
• if a patient is interactive: assess motor and sensory function (neuro)

Question 20

What are ‘E’ components in (ABCDE)?

Answer 20

Exposure

• undress patient completely -> examine patient’s body (including back) for other injuries
• blanket - if hypothermia
• palpate for rectal injuries and anal tone (PR)

Question 21

What can be a gross haematuria sign of?

Answer 21

bladder, kidney, urethral injury

Question 22

What can be a microscopic haematuria sign of in a setting of trauma?

Answer 22

Microscopic haematuria is normal after trauma in adults - but should be investigated in paediatrics

Question 23

When do we perform a secondary survey?

Answer 23

After:

• primary survey (ABCDE) has been completed
• patient is stable

Question 24

Components of secondary survey

Answer 24

• throughout examination
• history

Question 25

Free fluid in splenorenal recess

• what does it look like?
• what does it indicate?

Answer 25

Free fluid in splenorenal recess

It is an anechoic area between left kidney and spleen

It indicates the presence of free abdominal fluid

Question 26

FAST exam in the setting of trauma

• what is it?
• what is it used for?

Answer 26

FAST = Focused Assessment with Sonography for Trauma

• rapid, standardized bedside USS of polytrauma
• it is to screen for the presence of free fluid -> which may mean blood (internal hemorrhage)

Question 27

What areas are examined on FAST (4)?

Answer 27

FAST -> looks for free fluid (e.g. blood)

Areas of examination:

• peri-hepatic space and hepato-renal space
• peri-splenic and splenorenal space
• pelvis and suprapubic region
• pericardium

Question 28

What is the main goal of the secondary survey?

Answer 28

To reduce the risk of ‘missed injuries’

Question 29

Tertiary survey

• when is it performed?
• what is it aim?

Answer 29

• delayed re-examination of the patient (usually ∼ 24 hours after admission)
• main goal is to detect changes due to previously undetected injuries