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
CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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