Major Trauma Scenarios Ballarat Health Services Emergency Medicine Training Hub
Trauma Scenario 1 You receive a phone call from the ambulance service. They have a 27 yr old male involved in a MCA, he is conscious alert, the car has rolled he has been ejected from the vehicle. He has a probable #femur and compound # tib/fib how are you going to prepare?
Trauma Scenario 1 Trauma preparation Trauma call personnel trauma team radiology pathology department equipment
Trauma Scenario 1 Arrival history as above patient conscious, alert, orientated HR145 BP100/50 RR30 complaining of severe pain in R leg Deformity upper leg and obvious compound R tib/fib what is your approach? Image from http://lifeinthefastlane.com/2010/07/broken-open/
Trauma Scenario 1 Primary survey airway intact breathing decreased air entry L hemithorax What else would you look for?
Trauma Scenario 1 Assessment of pneumothorax tension pneumothorax hypotension tracheal deviation decreased chest movement venous engorgement Circulation HR145 BP100/50 RR30 What is your approach?
Trauma Scenario 1 Management tension pneumothorax approach to pneumothorax if tension manage with needle decompression then ICC CXR re-check ABC
Trauma Scenario 1 once AB stable re-check C continued hypotension N saline bolus D E rest of trauma series radiology analgesia femoral N block + iv analgesia head to toe examination
Trauma Scenario 2 A patient presents following a MCA, the other driver was killed, she left the scene and brought herself to hospital. She is complaining of abdominal discomfort and back pain. what is you approach?
Trauma Scenario 2 Approach to trauma Primary survey ACBCx CXR,CX,Pelvis Secondary survey head to toe include log roll IDC NGT
Trauma Scenario 2 Primary survey primary survey Airway normal you apply cervical collar Breathing normal Circulation HR140 BP100/45 RR35?approach
Trauma Scenario 2 hypotensive trauma Resuscitate circulation analgesia secondary survey marked seat belt bruising over mid/lower abdomen abdomen tender generalised guarding log roll thoracolumbar junction tender with bruising PR NAD
Trauma Scenario 2 abdominal trauma surgical registrar review CXR Lateral lumbar spine # L1 through posterior elements what other injuries are likely? what further investigations do you require?
Trauma Scenario 2 Chance fracture fracture of L1 hyperflexion transverse fracture through posterior elements +/- body associated injury to pancreas duodenum 4th part kidney liver/spleen retroperitoneal haemorrage
Trauma Scenario 2 investigation CT abdomen dual contrast additional treatment NGT, IDC Tetanus toxoid/antibiotics if required police bloods next of kin disposition
Trauma Scenario 3 A 20 yr old presents via ambulance after falling from his motorcycle. He is conscious, complains of neck discomfort and shortness of breath. What is your approach?
Trauma Scenario 3 Primary survey Airway - intact Cervical collar and sand bags Breathing - limited chest expansion but equal air entry Circulation HR 80 BP90/50 RR 30 What is the cause of this patient s hypotension What is your approach?
Trauma Scenario 3 Hypotensive trauma Loss-haemorrhage internal/external redistribution vasodilation eg spinal shock pump failure cardiac contusion loss cardioaccelerator obstruction to venous return tension pneumothorax pericardial effusion
Trauma Scenario 3 Hypotensive trauma response exclude obstruction to venous return fluid bolus no response to fluid bolus CXR normal what now?
Trauma Scenario 3 Hypotensive trauma Repeat fluid bolus BP 100/50 HR 80 Debility GCS 15/15 flaccid paralysis of both legs sensory level at level of upper chest what do you do next?
Trauma Scenario 3 trauma series Xrays Cervical spine Pelvis CX spine shows # dislocation at C6/7 What are the priorities with this patient?
Trauma Scenario 3 spinal trauma treatment priorities breathing loss of intercostals exhaustion spinal shock temperature control fluid balance important risk of over-filling IDC important steroids controversial increases morbidity referral to specialist unit
Trauma scenario 4 47 yr old woman presents via ambulance she was trapped between her car and a car that reversed into her in the supermarket car park. She is conscious but confused, complaining of pain in her tummy. What is your approach?
Trauma scenario 4 Primary survey ABCx normal C HR120 BP 80/60 RR 32 Approach to hypotension?
Trauma scenario 4 Hypotensive trauma Fluid bolus CXR & CX spine normal Pelvic Xray shows # body pubis with separation anteriorly # through sacrum no response to initial fluid bolus What is the cause of the hypotension? What is your assessment & management?
Trauma scenario 4 Pelvic Fracture Open book AP compression pelvic fracture Hypotension due to haemorrhage pelvic veins other abdominal injury
Trauma scenario 4 Approach to pelvic fracture secondary survey Including AMPLE history abdominal examination tender and guarding lower abdomen approach? PV blood at meatus IDC blood Log roll sacral pain and tender
Trauma scenario 4 Pelvic # and Hypotension Call orthopaedic Reg ASAP Repeat fluid bolus +/- blood close # MAST suit wrap C clamp Exclude other abdominal organ injury CT abdomen dual contrast US FAST