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Mx of the major trauma patient


initial Mx in ED

  • call a ED major trauma call to ensure the trauma team is in attendance and a team leader and various team roles are assigned
  • senior experienced leaders are generally need to ensure risk - benefit of interventions are appropriate, and that timely and appropriate Mx which minimises patient risk is attended without unnecessary extremes of Mx
  • secondary (delayed) neural injury in patients with moderate to severe brain trauma can be reduced by:
    • maintenance of airway and ventilation through early intubation and strict avoidance of hypoxia
    • maintenance of cerebral perfusion pressure through maintenance of systolic BP > 100mmHg and perhaps elevation of head by 30deg to reduce intracranial pressures

primary survey

  • this is aimed at:
    • providing spinal protections
    • institution of life saving measures such as:
      • Airway - securing an airway
      • Breathing - maintain ventilation
        • place intercostal catheter if any pneumothorax and intubation is required
      • Circulation:
        • minimise ongoing blood loss
          • local compression
          • consider hypotensive resuscitation - allow lower BP target as excessive fluid loading risks further blood loss, coagulopathy, etc.
        • large bore iv access
        • send bloods such as FBE, U&E, coagulation profile, cross match
        • maintaining the circulation
      • Disability:
        • brief assessment of neurologic state - GCS, gross focal neurology
        • identify other immediate life threatening problems
      • Exposure:
        • remove clothes to allow inspection of injuries and access for plumbing
        • maintain body temperature
    • assume the worst and institute measures as appropriate such as:
      • insert indwelling catheter if patient has been intubated and no C/I to IDC insertion (eg. urethral trauma)

secondary survey

  • a head to toe examination looking for specific injuries
  • log roll to assess back and spine as well as anal tone
  • signs of possible spinal cord injury in an unconscious trauma patient include:
    • paradoxical breathing in absence of major airway obstruction or large flail chest
    • preserved facial grimace in absence of pain response in limbs
    • lower limb flaccidity with normal upper limb tone
    • observed upper limb movement in absence of lower limb movement
    • bradycardia with hypotension despite fluid challenge
    • flaccid anal tone
  • baseline radiology plus specific radiology of urgent injuries suspected from survey

indications for neurosurgical consultation &/or transfer to a major Trauma Service

  • as per Victorian State Trauma Committee 2010

neurological deficits

  • deterioration of neurologic status (eg. drop of GCS of 2 points or more, seizure, increasing headache, new CNS signs)
  • confusion (eg. GCS < 13) or other neurological disturbance > 2 hours
  • persisting headache and vomiting 2 hours post-injury
  • GCS < 9 after resuscitation

skull fracture

  • skull fracture with confusion, decreased level of consciousness, seizure, focal neurological signs, or any other neurological signs or symptoms
  • compound skull fracture or penetrating injury - known or suspected
  • depressed skull fracture
  • suspected base of skull fracture (eg. blood &/or clear fluid from nose or ear; periorbital haematoma, mastoid bruising)

abnormal CT scan findings

  • intracranial haematoma
  • cerebral oedema
  • aerocele
  • midline shift

in Victoria, if not in a Major Trauma Service

  • NB. compliance with the following is being audited via VSTORM

contact ARV for disposition advice if fits criteria of "major trauma" as defined by any one of:

  • high risk mechanism of injury (MOI):
    • ejected from vehicle
    • motorcyclist or cyclist impact > 30kph
    • fall from height > 3m
    • struck on head by falling object > 3m
    • explosion
    • high speed MCA > 60kph
    • pedestrian impact
    • prolonged extrication > 30 minutes
  • high risk trauma patients:
    • age > 55yrs
    • pregnancy
    • significant underlying medical condition
  • high risk abnormal vital signs (adult values):
    • RR < 12 or >24/min
    • BP < 90mmHg
    • HR > 124/min
    • GCS < 13
    • SaO2 < 90%
  • high risk injuries:
    • penetrating injury to head, neck, chest, abdomen, pelvis, axilla or groin
    • significant blunt injury to head, chest, abdomen, axilla or groin
    • two or more of the above body regions injured
    • limb threatening injuries
    • amputated limb
    • suspected spinal cord injury
    • burns > 20% or suspected to involve the respiratory tract
    • serious crush injury
    • major compound fracture
    • open dislocation
    • fracture to two or more of femur, tibia, or humerus
    • fractured pelvis
trauma_mx.txt · Last modified: 2020/02/22 10:20 (external edit)