Symposium - The Multiple Injured Patient

Question 1

What are possible complications of trauma?

Answer 1

• Death
  
  • Leading cause of death in first 4 decades life
• Disability
  
  • For every death, there are 2 survivors with disability

Question 2

Where is good quality trauma care provided?

Answer 2

• Prevention
• Pre-hospital care
• Acute trauma care
• Specialised definitive care
• Rehabilitation

Question 3

What is a trauma network?

Answer 3

Trauma network = all providers, such as pre-hospital services, smaller local trauma units and larger trauma centres and rehabilitation services

Question 4

What are major trauma centres?

Answer 4

Major trauma centres = centres providing multi-specialty hospital care to seriously injured patients, optimised for the provision of trauma care

Question 5

Describe the process in a truma centre when a patient is inbound?

Answer 5

1. Pre-alert
   
   1. Alerts team patient on the way
   2. Team made up of ED, anaesthetics, radiology and surgical specialities
   3. Equipment and drug set up before arrival
2. Paramedic handover
   
   1. Includes – time of injury, mechanism of injury, suspected serious injuries, vital signs, interventions carried out
3. Trauma assessment
   
   1. Primary survey – ABC (airway, breathing and circulation) to detect and treat immediate threats to life
   2. Secondary survey – done after patient stabilised to identify all injuries and more detailed history

Question 6

Who makes up the trauma team?

Answer 6

1. Team made up of ED, anaesthetics, radiology and surgical specialities

Question 7

What is discussed in the paramedics handover?

Answer 7

1. Includes – time of injury, mechanism of injury, suspected serious injuries, vital signs, interventions carried out

Question 8

What is a primary and secondary survey?

Answer 8

1. Primary survey – ABC (airway, breathing and circulation) to detect and treat immediate threats to life
2. Secondary survey – done after patient stabilised to identify all injuries and more detailed history

Question 9

What are the different approaches to the primary survey?

Answer 9

• Advanced trauma life support (ATLS)
  
  • “ABC” approach
  • Airway with C-spine control
  • Breathing with oxygen
  • Circulation with haemorrhage control
  • Disability
  • Exposure and environment
• Battlefield advanced trauma life support (BATLS)
  
  • “ABC”
  • C at start for catastrophic haemorrhage control
    
    • This is haemorrhage leading to cause of death in military trauma (ballistic/explosive)

Question 10

What does ATLS stand for?

Answer 10

Advanced trauma life support

Question 11

Describe the steps of advanced trauma life support (ATLS)?

Answer 11

• “ABC” approach
• Airway with C-spine control
• Breathing with oxygen
• Circulation with haemorrhage control
• Disability
• Exposure and environment

Question 12

What does BATLS stand for?

Answer 12

• Battlefield advanced trauma life support (BATLS)

Question 13

Describe the steps of BATLS?

Answer 13

• “ABC”
• C at start for catastrophic haemorrhage control
  
  • This is haemorrhage leading to cause of death in military trauma (ballistic/explosive)

Question 14

What does management of airway and C-spine control include?

Answer 14

• Assessment
  
  • Noises: speech, gurgling, stridor
  • Visual: swelling, deformity, vomit, blood, debris
• Airway management
  
  • Manoeuvres
  • Suction
  • Adjuncts
  • Advanced procedures (intubation)
• Assume cervical spine injury in
  
  • Dangerous mechanism
  • Reduced conscious level
  • Injury above clavicles
  • Neurological signs

Question 15

What is done for airway management?

Answer 15

• Manoeuvres
• Suction
• Adjuncts
• Advanced procedures (intubation)

Question 16

What is used to assess the airway?

Answer 16

• Noises: speech, gurgling, stridor
• Visual: swelling, deformity, vomit, blood, debris

Question 17

When should cervical spine injury be presumed?

Answer 17

• Dangerous mechanism
• Reduced conscious level
• Injury above clavicles
• Neurological signs

Question 18

What is involved in the management of breathing and oxygen?

Answer 18

• Look
  
  • Visible injuries
  • Respiratory rate
  • Effort/expansion
• Feel
  
  • Palpate
  • Percuss
• Listen
  
  • Auscultate
• Oxygen, analgesia, drain

Question 19

What is involved in the management of circulation?

Answer 19

• Assessment
  
  • Heart rate
  • Palpable radial pulse
  • CRT
  • BP
  • Pulse pressure narrows
  • Urine output
  • Confusion
• Blood tests
  
  • HB
  • Lactate
• Imaging
  
  • Ultrasound
  • CT
• Haemorrhage control
• Volume replacement
  
  • IV access
  • IO access (into medulla of bone)
  • Type of fluid
  • Amount of fluid
  • Massive transfusion protocols
• Monitor volume replacement
  
  • Vital signs
  • Urine output
  • Lactate

Question 20

How is circulation assessed?

Answer 20

• Assessment
  
  • Heart rate
  • Palpable radial pulse
  • CRT
  • BP
  • Pulse pressure narrows
  • Urine output
  • Confusion
• Blood tests
  
  • HB
  • Lactate
• Imaging
  
  • Ultrasound
  • CT

Question 21

How is the fluid replacement monitored?

Answer 21

• Vital signs
• Urine output
• Lactate

Question 22

What are the 5 possible places for blood loss?

Answer 22

• Lose into
  
  • Floor
  • Chest
  • Abdomen
  • Pelvis
  • Long bones

Question 23

Describe the lethal triad that significant bleeding causes?

Answer 23

• Coagulopathy
• Acidosis
• Hypothermia

Question 24

What is involved in management of disability?

Answer 24

• Neurological examination
  
  • AVPU
  • GCS
  • Pupils
  • Tone and reflexes
  • Log roll

Question 25

What is involved in exposing and environment?

Answer 25

* Log roll and expose to allow full examination * Then cover up for warmth

Question 26

What should be added to ABCDE of ATLS?

Answer 26

Don’t forget G: * Check for glucose * Other bed side tests * ECG * Arterial blood gas * Urine dipstick

Question 27

Describe the secondary survery?

Answer 27

* Ultrasound * Fast scan (focus assessment with sonography for trauma) * Then CT * Minimal handling * Possibly no log roll * Trauma mattress * Don’t spring the pelvis

Question 28

What happens after the primary and secondary survery?

Answer 28

Transfer and further management: * Theatre * Operative management * Interventional radiology * Control of bleeding * ITU * Intracranial pressure monitoring