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