Trauma Scenario #1

Ensure the patient is managed in the resuscitation bay and that a trauma call has been put out
Immediately perform a rapid primary survey in an A to E manner with simultaneous resusctiation following the ATLS protocol
Prescribe adequate analgesia using the WHO pain ladder

Apply 15L oxygen through a non-rebreather mask
Ensure triple immobilisation of the cervical spine
Assess airway patency, checking for foreign bodies, or signs of head and neck fractures

Check oxygen saturations and respiratory rate
Check the trachea is central
Inspect, auscultate, palpate and percuss the chest
ABG

I am concerned this patient is in shock, which in trauma is haemorrhage until proven otherwise
I most suspect the source of haemorrhage may be abdominal as the patient is in severe abdominal pain but would fully assess the patient to rule out other sources
I would escalate to my senior for early support
Check blood pressure and heart rate
Palpate central and peripheral pulse for regularity, volume and rate
Assess the jugular venous pressure
Check peripheral and central capillary refill times
Assess temperature of peripheries
Assess the abdomen for bruising, guarding or peritonism as well as the chest, pelvis and limbs for sources of haemorrhage
Insert x2 large-bore peripheral cannulas
Obtain blood samples for FBC, CRP, U&Es, LFTs, beta hCG for all females of childbearing age, and group and save
Obtain a venous blood gas with a lactate
Initiate fluid resuscitation with 1L of warmed intravenous Hartmann's
If unresponsive to crystalloid therapy, consider transfusion of O negative or type=specific blood in major haemorrhage
Consider activating major haemorrhage protocol to manage coagulopathy
Consider 1g tranexamic acid IV
Urinary catheter insertion to monitor urine output and check for haematuria
Continuous electrocardiography
Request chest x-ray, pelvic x-ray and/or FAST scan to further investigate for thoracic, pelvic or abdominal sources of haemorrhage
Reassess the patient following interventions

Establish GCS
Assess pupillary size and reaction
Blood sugar level
Monitor temperature
Warm the patient to prevent hypothermia
C

Do a full top-to-toe examination, checking for missed injuries
whilst preventing hypothermia
and maintaining patient dignitiy

To complete the assessment I need to do secondary and tertiary surveys and take an AMPLE history
Escalate to seniors for review
Re-assess in the meantime to monitor response to interventions and detect deterioration early
Prepare the patient for theatre: Make the patient NBM and prescribe IV fluids, alert the surgical registrar on-call, discuss the case with the on-call anaesthetist for pre-op review, alert the theatre co-ordinator, book the patient onto the emergency list, prepare a consent form

I am most unwell about an intra-abdominal haemorrhage as the patient is critically unwell and in stage III shock. Sources of the abdominal haemorrhage include:
Splenic rupture
Liver laceration
Genitourinary injury
Vascular injury
Retroperitoneal haemorrhage
I would want to exclude other sources of haemorrhagic shock including haemothorax, pelvic fracture, long-bone fracture, or external injuries

Bloods: FBC, U&Es, LFTs, Coagulation screen, Lactate, G&S, Cross-match 4 units
Arterial or venous blood gas
FAST scan
CT Abdomen with contrast or CT angiogram as part of the CT Trauma series if the patient is stable enough for transfer

As the patient is haemodynamically unstable with a proven splenic laceration the patient is likely to need surgical or interventional radiological management
Reassess in an A to E manner with appropriate resusctiation, considering blood products
Escalate promptly to senior
Involve the multi-disciplinary team including senior trauma or general surgeon, interventional radiologist, anaesthetist, critical care outreach team as this patient may need an ITU bed and the senior A&E clinician
Prepare the patient for threatre, which includes:
Make the patient NBM and prescribe IV fluids
Discuss the case with the on-call anaesthetist for pre-op review
Alert the theatre co-ordinator
Book the patient onto the emergency list
Prepare a consent form

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