Injuries in Multi-Trauma Hot Case
GENERAL APPROACH
Approach
- Stage of illness — e.g. resuscitation, acute stabilisation
- Primary, secondary or tertiary survey (examine from head to toe)
- Complications of stay e.g. VAP
- Need for ongoing surgical management?
- Rehabilitation phase
Cases
- usually blunt trauma to MVC or falls
INTRODUCTION
CUBICLE
- long stay patient
- spinal bed
- traction
INFUSIONS
- resuscitation fluid being administered
- noradrenaline (sepsis, CPP management for TBI, spinal injury)
- hypertonic saline
- sedation and neuromuscular blocking agents (ask!)
VENTILATOR
- level of support
- level of oxygenation (FiO2, PEEP)
- disease specific questions (ARDS: plateau pressure, pulmonary contusions)
MONITOR
- ICP
- temperature
- tachycardia (SIRS)
- ETCO2 (in TBI as a surrogate for PaCO2)
- arterial trace (pressure, swing, pulsus paradoxus, hypotension)
EQUIPMENT
- cervical collar (not cleared or unstable injury)
- Edgerton bed for spinal injury
- ICCs (swing, bubbling, blood)
- intra-abdominal drains
- urine (output, myoglobinuria)
- external fixators
- traction
- plaster of paris
- cooling blankets (refractory ICP management or hyperthermia)
QUESTION SPECIFIC EXAMINATION
- expose patient as much as possible
- primary survey: if stable then proceed with secondary survey
- secondary survey: head -> neck -> arms -> chest -> abdomen -> legs examination -> back and ask re: PR/PV
- neurological
-> paralysed
-> quick examination
-> unconscious
-> conscious
-> spinal injury (levels, bulbocavernosus reflex)
Questions
- type of penetrating implement?
- mechanism, speed?
- restrained, damage to vehicle, death at scene?
- GCS at scene (before and after resuscitation)?
- spinal integrity/ clearnace?
- tracheal secretions (blood stained)?
- N/G aspirates?
- tetanus status?
- compound orthopaedic injuries and wounds washed out?
- further surgery planned?
RELEVANT INVESTIGATIONS
- CK
- radiology: CXR, spine, pelvic, CT, long bones
- liaising with other appropriate teams
OPENING STATEMENT
- “My assessment follows a primary and secondary survey. Injuries from head to toe including relevant injuries are…”
- “I would like to review imaging…”
- “My plan for the next 24 hours is…”
- “I would like to liaise with the other treating teams…”
DISCUSSION
- pelvic fractures and haemorrhage
- TBI management, indications for ICP monitoring and decompressive craniectomy
- seizure prophylaxis post-TBI
- management of refractory ICPs
- thromboprophylaxis
- steroids in spinal injury
- abdominal compartment syndrome
- trauma scoring systems
- damage control resuscitation
- factor 7
- assessment and clearance of the cervical spine
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC