SAQ 1
Monash Health Practise Exam
2014.2
A 25 year old female pedestrian is brought in to your
tertiary emergency department by ambulance having been hit
by car. She has bruising over her abdomen and a deformity of
her right femur. Her observations are as follows:
GCS 10 (E2, V3, M5)
PR 160
BP 60/40
A bedside eFAST ultrasound exam is performed which shows
free fluid in Morison’s pouch. A plain bedside CXR shows no
abnormality and a pelvic xray shows a vertical shear fracture.
Outline your management (100%)
Management
• Those aspects of care of the patient
encompassing
– treatment
– supportive care
– disposition
Management
Treatment
Supportive care
Disposition
Management
Manage ABC / Resuscitation
Specific treatment
Supportive care / monitor progress
Manage complications
Communication
Consultation
Disposition
Management
Label problem
Degree of urgency
Key issues / opening statement
Manage ABC
Resuscitation
Specific treatment
+/- Criteria for Rx
+/- Goals of treatment
Supportive care / monitor progress
Manage complications
Communication / Consultation
Patient / Family / Medical consultation
Degree of urgency
Disposition
+/- Criteria eg for ICU
+/- Other
A 25 year old female pedestrian is brought in to your
tertiary emergency department by ambulance having been hit
by car.
She has bruising over her abdomen and a deformity of her right
femur.
Her observations are as follows:
GCS 10 (E2, V3, M5)
PR 160
BP 60/40
A bedside eFAST ultrasound exam is performed which shows
free fluid in Morison’s pouch. A plain bedside CXR shows no
abnormality and a pelvic xray shows a vertical shear fracture.
Outline your management (100%)
25 year old female
Pedestrian vs car
tertiary emergency department
bruising over her abdomen/ free fluid in Morison’s pouch
vertical shear fracture pelvis
# right femur
PR 160
BP 60/40
GCS 10 (E2, V3, M5)
eFAST & CXR
Outline your management
• Bruising over her abdomen/ free fluid in Morison’s
pouch
– Intra-abdominal injuries with haemorrhage and or
perforation ( liver spleen renal bowel)
– 40% Pelvic # have additional intra-abdo bleeding source
• vertical shear fracture pelvis
– Massive blood loss
– ? Degree of displacement
– Ideally reduce before binding
• # right femur
– Moderate blood loss
– Traction to reduce
– Concern traction devices impinge on pelvis
Outline your management
PR 160 / BP 60/40
Grade 4 Haemorrhagic shock
Activate MTP (massive transfusion protocol)
DCR (Rx of traumatic haemorrhagic shock)
DCS
GCS 10 (E2, V3, M5)
20 to Shock
10 Head Injury/TBI (EDH SDH ICB)
Setting up your answer
• Where is this pt?
– Tertiary centre
– Already has had CXR eFAST pelvicXRay
• Who do you need?
– Trauma Call
– Team Approach
– Who will lead?
ABC/Resus
• A
– GCS 10
• Modified RSI ( drug choice, dose, inline Cx spine )
• Intubation could wait until DCS if airway protected by GCS>8
• Neuroprotective measures if TBI
– Cervical ( & full spine) Immobilzation
• B
– High flow O2
• Don’t expect major chest involvement with normal CXR /eFAST
• C
– MTP with detail (PC/FFP/Plt)
• +/- warmers/cell savers etc
– O/Neg then Type Specific blood
• Normal saline until blood available (avoid large volume crystalloid)
– Administration of Tranexamic Acid
• 1gm/10min then 1gm /8hrs
– Aims/Endpoints
• Mx coagulopathy/acidosis/BP/HR/temp
– Role of Permissive Hypotension in this pt
• C/I in pt with TBI
Pelvic #’s
• Pelvis
– Major Haemorrhage associated with AP & VS (not usually LC)
– The major blood loss is from:
• Bony surfaces
• venous plexus from ant. branches of the internal iliac artery
• the superior gluteal artery (as it passes through the sciatic notch)
– Retroperitoneal space can hold 4 litres of blood.
– Exclude intraabdominal bleeding - 40% of patients with pelvic
fractures have an intraabdominal source of bleeding.
– fracture site is the major cause of bleeding in 85%
• external pelvic stabilisation should be used.
• Steps to control pelvic bleeding:
– External Fixation
– Pelvic packing (if no other source of bleeding found) plus
optimize fixation
– Angiogram & embolisation
Specific Rx
• Pelvis
• Binder
–Is this ideal for vertical shear #s?
–Will not stop arterial bleeding
• Consider temporizing ED ex-fix ( ortho)
• Femur
• Traction & splinting
• HOW?
• Can it wait?
Supportive Rx
• IDC
– This needs specific recognition of issues with
pelvic # and urethral/bladder damage
•
•
•
•
•
Analgesia
ADT/Antibiotics (if open wounds)
Wounds/external bleeding first aid
Temperature maintanence
Glucose control
Communication & Consultation
• Family/NOK
• Inpatient specialties
– If Listed in trauma call don’t need to repeat
• Documentation
Disposition
• OT then ICU
– Is this enough detail?
Disposition
• OT
– DCS
• Laparotomy
• Pelvic fixation/packing
• Angiography/Interventional Radiology
– If negative FAST or isolated pelvic injury
– Post surgery for abdominal control
• Ideal for bleeding from int iliac artey branches
• ICU
• Definitive Imaging & Fixation
Pitfalls in answering
• Generic statements
– Seek & treat all life threats without examples
– Full primary & secondary survey without detail
• Piecemeal Management
• Conflicting statements
– Permissive hypotension for bleeding but maintain CPP/BP
for TBI
• Word choices
–
–
–
–
–
Likely …
Consider…
May….
Then if ….
Precaution vs Immobilization for Cervical spine