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trauma_mx [2020/02/22 10:20] (current)
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 +====== Mx of the major trauma patient ======
  
 +see also:
 +  *[[trauma]]
 +  *[[http://​trauma.reach.vic.gov.au/​sites/​default/​files/​Early%20Trauma%20Care_31102017_0.pdf|Vic Trauma Guidelines - Early Trauma Care]]
 +  *[[http://​trauma.reach.vic.gov.au/​resources/​trauma-victoria-guideline-pdf|Vic Trauma guidelines main index]]
 +
 +=====introduction=====
 +  *the following are general Mx processes for patients who fit criteria for a [[trauma_call]]
 +
 +
 +=====initial Mx in ED=====
 +  *call a [[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====
 +<note warning>
 +  *don't forget decreased GCS or low BP may be due to pre-existing condition prior to trauma eg. [[AMI]], drugs, [[anaphylaxis]],​ [[seizures]],​ etc.
 +</​note>​
 +  *this is aimed at:
 +    *providing spinal protections
 +    *institution of life saving measures such as:
 +      ***A**irway - securing an airway
 +        *consider early [[rsi]]
 +      ***B**reathing - maintain ventilation
 +        *place intercostal catheter if any [[pneumothorax]] and intubation is required
 +      ***C**irculation:​
 +        *minimise ongoing blood loss
 +          *local compression
 +          *consider //​hypotensive resuscitation//​ - allow lower BP target as excessive fluid loading risks further blood loss, coagulopathy,​ etc.
 +          *consider [[tranexamic_acid]]
 +        *large bore iv access
 +        *send bloods such as FBE, U&E, coagulation profile, cross match
 +        *maintaining the circulation
 +          *iv fluids +/- blood transfusion for hypovolaemic [[shock|shock]]
 +            *consider activating [[blood_massive|massive transfusion protocols]]
 +          *relieve any tension [[pneumothorax]] by digital decompression rather than needle decompression
 +          *cardiogenic shock may be due to:
 +            *myocardial contusion, [[cardiac_tamponade]] (which may require [[resuscitative_thoracotomy]] if in a trauma centre)
 +          *neurogenic shock from spinal injury:
 +            *characterised by bradycardia
 +      ***D**isability:​
 +        *brief assessment of neurologic state - GCS, gross focal neurology
 +        *identify other immediate life threatening problems
 +      ***E**xposure:​
 +        *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
 +    *[[priapism]]
 +    *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**
 +    *as a minimum:
 +      *CXR
 +      *pelvis Xray
 +      *cervical spine imaging (usually CT scan) unless can be cleared clinically
 +      *brain CT scan if [[head_injury_adult&#​indications_for_ct_brain_in_adults_with_head_injury|indication for CT brain in adults]]
 +    *[[us_FAST|FAST ultrasound scan]] if available
 +    *consider chest/​abdo/​pelvis CT scan
 +
 +=====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 ยท Last modified: 2020/02/22 10:20 (external edit)