Trauma Scenario #2

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

The tachypnoea, low saturations and tachycardia mean I'm worried about a life-threatening thoracic injury such as tension pneumothorax or haemothorax
Check oxygen saturations and respiratory rate
Check the trachea is central
Inspect, auscultate, palpate and percuss the chest
ABG
Make a request for a portable chest x-ray
If my clinical findings are suggestive of a life-threatening thoracic injury I would manage it immediately, re-assess and escalate this to my seniors before continuing to C

Check blood pressure, heart rate and connect patient to a continuous cardiac monitor as in resus
Palpate central and peripheral pulse for regularity, volume and rate
Examine for elevation of 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

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

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 concerned about a left-sided tension pneumothorax
This requires immediate intervention so I would insert a large-bore needle or cannula in the left anterior to the mid-axillary line through the 5th intercostal space
I would then re-assess the patient to look for improvement and in the meantime prepare to insert a chest drain
The chest drain needs to be inserted again left-sided anterior to the mid-axillary line through the 5th intercostal space with the drain connected to a closed drainage system
The patient needs a chest x-ray to confirm tube position and lung re-inflation
In this context a patient will need CT Trauma series to assess for other injuries

This is a massive haemothorax
Re-assess in an A to E manner
Commence appropriate resuscitationwith fluids and blood products
Activate the major haemorrhage protocol
Escalate to my seniors
Contact the cardiothoracic team and the critical care outreach team
Review the available bloods specifically the haemoglocin and coagulations creen, and contact haematology for advice on administration of blood fractions or correction of coagulopathies
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

A life-threatening, acute accumulation of blood in the pleural cavity, defined as the rapid drainage of > 1,500 mL of blood upon tube thoracostomy, or sustained bleeding of > 200 mL/hour for 2 to 4 hours

Lack of swinging means there’s no pressure change being transmitted to the drainage system
This could be due to a blocked drain, e.g. due to a clot or kink, the drain could be displaced and no longer intrapleural, or the lung has fully re-expanded
I would immediately assess the patient to check if they are stable or hypoxic,
inspect the whole system from patient to bottle looking for kinks or clots
consider getting a chest x-ray,
escalate to my senior if I need their support

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