Major TraumaScenarios

Ballarat Health ServicesEmergency 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 rollthoracolumbar junction tender with bruisingPR 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 meatusIDC bloodLog roll sacral pain and tender

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”

Trauma scenario 4

Pelvic # and Hypotension