TRAUMA FINAL

Scene approach

• PPE

• ETHANE/scene safety

• MOI

• General impression

• AVPU

• Primary survey

• Rapid trauma survey

• Pre-alert

• Transport

• Focussed assessment

• History

Drug checks

• Pain scale

• Five R’s

• Contraindications

• Repeat

• Max dosage

• Cross check

GCS eyes

• Spontaneous 4

• Voice 3

• Pain 2

• None 1

GCS verbal

• Orientated 5

• Confused 4

• Inappropriate words 3

• Incomprehensible sounds 2

• None 1

GCS motor

• Obeys command 6

• Localises to pain 5

• Withdraws from pain 4

• Flexion to pain 3

• Extension to pain 2

• No response 1

IO injection

• Swab site

• Prime set with sodium chloride

• Remove safety cap (blue needle)

• 90 degree angle tibia tuberosity (2 fingers from patella and two in)

• Push needle til tip hits (5mm still visible) then drive

• Remove sharps

• Secure with adhesive

• Aspirate for blood/bone marrow

• Flush 5-10mLs

• Wrist band on

Cardiogenic shock symptoms

• Severe bradycardia

• Severe tachyarrhythmia

• Myocardial contusion

• Beta-blocker overdose

• Calcium-channel blocker overdose

• SOB

• Hypotension

• Fast, weak, irregular heartbeat

• Sudden, heavy sweating

Obstructive shock symptoms

• Tension pneumothorax.

• Cardiac tamponade.

• Massive pulmonary embolism.

• Beck’s triad

  • Decreased blood pressure

  • Jugular venous distension

  • Diminished heart sounds

Neurogenic shock management

• Manage spinal

• Large bore IV 2 x 18g

• Compound sodium lactate 250mL bolus

  • Target MAP 80-85mmHg

  • diastolic BP + ⅓ (systolic BP - diastolic BP)

• Treat significant bradycardia.

  • Atropine 500 mcg 3-5 mins, max 3mg

Neurological assessment

• AVPU

• GCS

• AEIOUTIPS

• Blood glucose level

• FAST test

• Pupils (PEARL) and big H eye movement

• Coordination tests

cerebral contusion symptoms

• Prolonged unconsciousness.

• Profound confusion.

• Amnesia.

• Focal neurological signs.

• Personality changes.

Intracranial haemorrhage symptoms

• Epidural: mins to hours

  • Ipsilateral dilated fixed pupil

  • Signs of increasing ICP

  • Unconsciousness

  • Contralateral paralysis

  • Death

• Intracerebral haemorrhage: similar to stroke, headache and vomiting

cerebral herniation symptoms

• Cushing's triad

  • Hypertension / rising systolic BP.

  • Bradycardia.

  • Irregular respirations.

  • Indicates: ICP, impending cerebral herniation

• Rapidly decreasing LOC.

• Progression to coma.

• Ipsilateral dilated pupil.

• Abnormal eye position.

• Contralateral paralysis.

• Decerebrate posturing.

• Respiratory deterioration.

Cerebral herniation management

• Loosen anything around head and neck

• Recognise cushing reflex

• Oxygen

  • Ventilate 20bpm when herniation recognised 30-35mmHg, PEEP

• Large bore IV 2 x 18g

• Compound sodium lactate titrate to 120 systolic (reduce cerebral swelling)

• Ondansetron 4mg/2mL

• Transport head at 30-45 degrees

When to hyperventilate in cerebral herniation syndrome

• TBI with GCS <9 with

  • Decebrate posturing

  • dilated/non-reactive pupils

  • Initial GCS <9 followed by drop >2 points

• the immediate danger of herniation may outweigh the risk from reduced cerebral perfusion 

Cardiac tamponade signs

• Beck’s triad

  • Hypotension.

  • Distended neck veins.

  • Muffled heart sounds.

• Narrow pulse pressure.

• Tachycardia.

• Poor peripheral perfusion.

• Paradoxical pulse on inspiration

Cardiac tamponade treatment

• IV/IO access.

• Sodium chloride 0.9%, 250mL bolus to SBP 90–100 mmHg.

• Monitor/treat dysrhythmias

  • Atropine 600mcg/1mL bradycardia

  • Amiodarone 50mg/1mL tachycardia

Diaphragmatic tear symptoms

• Reduced breath sounds.

• Possible bowel sounds in chest.

• Scaphoid abdomen.

• More common on the left 

Diaphragmatic tear management

• Rapid transport for surgical management.

• No definitive prehospital correction.

Massive PE symptoms

• Sudden onset SOB

• Hypotension

• Tachycardia

• Distended neck veins

• Sharp chest pain/heavy pressure

• Cyanosis

Massive PE management

• 12 lead ECG

• IV access

• Anticoagulation/thrombolysis (breaks down clot)

  • IV unfractionated heparin (UFH) - prevents clot propagation

Liver injury symptoms

• Blunt abdominal trauma.

• Internal haemorrhage.

• Right upper abdominal pain.

• Referred right shoulder pain.

• Shock may occur with minimal external evidence.

• Seatbelt tucker under driver

spleen injury symptoms

• Blunt abdominal trauma.

• Left upper quadrant injury.

• Referred left shoulder pain.

• Shock with minimal external evidence.

• Seatbelt tucked under passenger

abdominal haemorrhage signs

cullen’s sign (bruising around umbilicus)

grey turner’s sign (flank bruising)

Evisceration management

• Fentanyl 25mcg 

• Do not push the viscera back 

• Cover with moist sterile gauze/pads.

• Use non-adherent covering.

• Flex knees if appropriate.

Burns management

• Identify type of burn and percentage

• Stop the burning process running water 20mins

• Compound sodium lactate as per parklands formula 

  • 4 mL × body weight (kg) × %TBSA burned

  • Gives fluid requirements for the first 24 hours.

  • ½ given in first 8 hours

• Remove wet clothing/items.

• Cover with:

  • Cling wrap where appropriate (vertical)

Epidermal burn

• Epidermis only.

• Red.

• Skin intact.

• No blisters.

• Brisk capillary refill.

• Heals spontaneously.

Superficial dermal burn

• Upper dermis involved.

• Pink.

• Blisters may be present.

• Brisk capillary refill.

Mid dermal burn

• Extends into mid dermis.

• Dark pink.

• Sluggish capillary refill.

Deep dermal burn

• Deep dermis involved.

• Blotchy red/white.

• Sluggish or absent capillary refill.

• Often requires surgical intervention.

Full thickness burns

• Entire dermis destroyed.

• May involve underlying tissue.

• White/waxy/cherry-red/brown/black.

• No capillary refill.

• Requires specialist/surgical management.

carbon monoxide poisoning symptoms

• Altered LOC.

• Features of smoke exposure.

• Cherry-red skin is possible but rare.

• Cyanosis may occur but is rare.

• Pulse oximetry may be misleading

smoke-inhalation management

• Remove from source

• Inhaled salbutamol 5mg in 2.5mL (relieves bronchospasm)

• PEEP

Compartment syndrome management

• Treat underlying injury.

• Splint fractures (PMS before and after)

• Position limbs at heart level

• Cold packs to severe contusion

Crush syndrome symptoms

• Severe local pain

• Swollen tense muscles

• Low blood pressure

• numbness/tingling

• weakness/paralysis

• Pale or cold skin

• Missing or weak pulse

• Hypotension

• Nausea 

Crush syndrome management

• Anticipate complications before release.

• 12 lead ecg

• Compound sodium lactate 20-30mL/kg bolus (support kidneys)

  •  continuous infusion of 20mL/kg/hr

• Treat hyperkalaemia.

  • Sodium bicarbonate 1mmol/kg in 1mL/kg IV (shift potassium into cells)

  • Calcium gluconate 1g/10mL IV (protects heart)

  • Salbutamol 5mg/2.5mL nebulised (shift potassium into cells)

hyperkalaemia symptoms

• Fatigue.

• Weakness.

• Paraesthesia.

• Paralysis.

• Palpitations.

• Bradycardia.

• Pauses.

• Dysrhythmias.

Hyperkalaemia management

• 12 lead ECG

• IV access ×2 if possible.

• Compound sodium lactate 20-30mL/kg bolus

  •  continuous infusion of 20mL/kg/hr

• Calcium gluconate 10%, 1g/10mL IV (protect the heart)

• Neb salbutamol 5mg in 2.5mL (shift potassium into cells)

• Sodium bicarbonate 1mmol/kg in 1mL/kg IV (shift potassium into cells)

heat stroke symptoms

• Core temperature higher than 40.5 degrees

• Hot, dry skin

• Altered mental status

• Anhidrosis ( cannot sweat normally)

  • May or may not be present

• Hyperventilation, hypoventilation, tachycardia

• Pulmonary oedema, seizures, abdominal posturing

• Rhabdomyolysis, pulmonary oedema, renal failure, cardiac dysfunction

Heat stroke management

• 12 lead ECG, monitor dysrhythmias

• Rapid cooling 0.1 degree/minute

  • Remove all clothing

  • Cold packs to neck, axillae, groin

  • Fanning 

  • Misting 

• Replace fluids and electrolytes

  • Compound sodium lactate 20mL/kg

  • IV if necessary calcium gluconate 1g IV/10mL

drowning types

fresh water = ventricular fibrillation

salt water = pulmonary oedema

beta blocker symptoms

• Bradycardia

• Hypotension

• Arrhythmias

• Changes in heart rhythm

• ALOC

• Seizures

• SOB

• Hypoglycaemia 

beta blocker overdose management

• IV access large bore 18g

• Compound sodium lactate 20mL/kg

• Atropine 600mcg/1mL IV

• Seizures: midazolam 2.5mg/2.5mL IV (1mL in 4mL sodium chloride)

• Hypoglycaemia: glucose 10% 15g/150mL IV

• Backup for adrenaline infusion