VIC FACEM Study Group 18th April 2015 Trauma SAQ’s
Question 1
A 37 year old male presents to your tertiary ED by ambulance after being involved in a
high speed motorbike accident. He was the rider and was found on the road 20 metres
from his bike. On arrival he is complaining of lower abdominal pain. He was given 2 litres
of Normal Saline pre-hospital as well as 10mg IV morphine.
He looks pale and his vitals are:
SaO2 96% on 8l/ min via Hudson mask
HR 110 sinus tachycardia
BP 80/60
Temp 34.6ºC
FAST scan - negative
A pelvic x-ray is performed as part of his primary survey
1. Give an interpretation of the x-ray, providing positive findings (2 marks)
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2. List potential other injuries in this patient (4 marks)
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3. List the management priorities for his haemodynamic instability (4 marks)
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Question 2
A 42 year old male presents to your tertiary ED by ambulance after being involved in a
high speed MVA. He was the driver, restrained, and airbags were deployed. On arrival he
is awake and alert, complaining of lower abdominal pain and appears to have isolated
abdominal injuries.
On initial assessment:
His vitals are:
SaO2 98% on 2L O2
HR 105
BP 90/60
GCS15/15
FAST scan - positive for free fluid in Morrison’s pouch
This is a picture of his abdomen:
1. Question List the potential injuries based on the appearance of the image provided and
the information above (4 marks)
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2. You have given him a 500ml crystalloid fluid bolus and his blood pressure is now
105/65. List your management priorities (3 marks)
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3. List the disposition options for this patient along with the factors that will influence your
decision (3 marks)
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Question 3:
A 29 year old woman is brought to the Emergency Department after an alleged assault by
her husband, claiming to have been punched and kicked repeatedly in the abdomen. She
is 32 weeks pregnant and has multiple bruises across the anterior abdominal wall.
She is alert, with a GCS of 15 and the following vital signs.
PR 110
RR 24
BP 90/50
Sats 97% on room air
She is complaining of severe
abdominal pain.
1: List five (5) complications of blunt abdominal injury in this patient (5 marks)
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2: What are the possible causes for her tachycardia? (5 marks)
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3: List two (2) investigations to assess fetal wellbeing and your rationale for their
use (4 marks)
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4: Which clinical features would prompt an immediate obstetric consultation (5 marks)
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Question 4
A 48yo man is brought to the ED after sustaining a single stab wound to the left side of his
chest. He is alert, GCS 15, vocalising normally but is pale, diaphoretic, and acutely short of
breath. His vital signs are:
PR
RR
BP
Sat
T
123
24
94/52
88% on 8L via Hudson mask
36
A chest x-ray is taken soon after his arrival:
1. List your immediate management priorities (6 marks)
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2. List 2 benefits and 2 limitations of bedside ultrasound in the assessment of this
condition (4 marks)
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3. What are the indications for urgent transfer to the operating theatre for surgical
management of this condition? (3 marks)
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ANSWERS:
QUESTION 1
1.1: Give an interpretation of the image, providing positive findings (2 marks)
- Open book pelvis with diastasis of the pubic symphysis
- Widening of the right sacroiliac joint
1.2: List potential associated injuries (4 marks)
Any 4 of the following:
- Closed head injury
- Femoral fractures
- Thoracic injury
- Bladder / GU injury
- Abdominal solid organ
- Hollow viscus injury
- Diaphragmatic injury
1.3: Outline the management priorities for his haemodynamic instability (4 marks)
- Apply pelvic binder / external compression using binder / sheets etc to reduce pelvic volume
- Haemostatic resuscitation / damage control resuscitation, massive transfusion, with early PRBC,
FFP, Platelets targeting coagulopathy of trauma
- Correct hypothermia
- Tranexamic acid 1g loading followed by 1g over following 8 hours
- Seek and treat other causes of blood loss - external compression, splinting of long bone
fractures
- Early involvement of interventional radiologist / trauma surgeon / orthopaedic surgeon to plan for
- Interventional angiographic embolisation
- Pre-peritoneal packing
- Pelvic stabilisation by external fixation
- Remember FAST negative so laparotomy other interventions prioritised above laparotomy
- REBOA not yet standard care / evidence based so don’t mention it
QUESTION 2
2.1: List the potential injuries based on the appearance of the image provided and the information
above (4 marks)
- Intra-abdominal solid organ injury - liver / spleen / pancreas
- Intra-abdominal hollow viscus injury - small bowel perforation, mesenteric tear
- Ruptured diaphragm
- Intra-peritoneal rupture of distended urinary bladder
- Spinal injury - e.g Chance fracture - Burst fracture lower T spine, L spine
- Blunt aortic injury / sternal fractures / clavicle fractures - you may not get marks for this as the
questions state - isolated injury
2.2: You have given him a 500ml crystalloid fluid bolus and his blood pressure is now 105/65. List
your management priorities (3 marks)
- Restrictive approach - permissive hypotension - aim for systolic BP around 90mmHg in order to
enhance vasoconstriction and clot stabilisation, whilst maintaining vital end organ perfusion
- Analgesia - small aliquots of IV opiate analgesia - e.g 50mcg Fentanyl
- Antibiotic prophylaxis if mesenteric injury suspected
- Maintain normothermia, correct acidosis,
- Prepare patient for CT
- NGT
- IDC
2.3 List the disposition options for this patient along with the factors that will influence your decision
(3 marks)
- Unstable haemodynamics plus positive FAST - theatre for laparotomy
- If stable, and fluid responsive - CT scan to evaluate intra-abdominal further and to identify other
injuries e.g - brain / spine / thoracic / pelvic
- Interventional radiology after CT in conjunction with radiologist if contrast blush or extravasation
identified on CT.
- HDU / ICU post theatre / IR for ongoing supportive management
QUESTION 3
3.1 Non pregnancy related
1) Solid organ injury: liver spleen kidney laceration
2) Retroperitoneal haemorrhage (more common in pregnancy)
3) Hollow viscus injury - rare
Pregnancy related
1) Placental abruption
2) Uterine rupture
3) Preterm labour
4) Feto-maternal haemorrhage
“Fetal death” – not really an answer – need to state from what
3.2
1)
2)
3)
4)
5)
May be normal for pregnancy
Pain
Supine hypotension/IVC compression
Hypovolaemia/haemorrhage
Other non-abdominal injury eg: tension pneumothorax
3.3
1) Bedside ultrasound: for cardiac activity, movement, presence does not exclude
serious injury
2) CTG (minimum 4-6 hours)
3.4
1)
2)
3)
4)
5)
6)
7)
8)
uterine contractions/tetany
significant uterine tenderness or irritability
vaginal bleeding
rupture of the amniotic membranes
presenting part visible
non-reassuring fetal heart rate pattern on CTG
no fetal heartbeat seen on bedsideultrasound
other serious maternal injury
Other potential obstetric trauma questions:
Peri-mortem c-section
- Everyone’s afraid of it, very hard to write a question on this topic for this type of
exam (Remember Don – complex procedures unlikely in OSCE…)
- Need to know:
- Indication: maternal arrest unresponsive to standard resuscitative treatment and
correction of supine hypotension
- Ideally decision to act within 4 minutes of arrest, baby out by 10 mins max (EAST
guidelines state may go out to 20 mins…)
- How you plan to do it: vertical-vertical, or vertical/horizontal incisions.
- Post procedure care
Indications for anti-D:
- See: http://www.transfusion.com.au/disease_therapeutics/fetomaternal/HDN
Who should attend a pregnant trauma resuscitation?:
- Usual trauma team including anaesthetist
- Obstetrician/O&G Reg (if in doubt in exam – get the Consultant)
- Midwife - essential
- Paediatrician/Paeds Reg (again, if in doubt in exam – get the Consultant)
Equipment to prepare prior to an obstetric trauma patient arriving:
Mother
- Usual resus equipment
- US for FAST but also for potential difficult IV access
- Airway: Ramp (if spinal precautions not required), short handled laryngoscope
- Breathing – no special equipment required, but ICC’s must go in higher (aim 3 rd-4th
IC space)
- Circulation – nothing special required, be aware of issues related to circulating
volume, can give O-negative to pregnant mothers, ideally only 2 units before
switching to type-specific or cross matched
Baby
- Rususcitaire/neonatal resus trolley with warmer
- Airway/breathing: Size 3-3.5 ETT, infant BVM or Neo-Puff on Resuscitatire, 5cm
H2O PEEP, start 100% O2
- Circulation – 24G IV, potential need for umbilical vein cannulation – best to get
paeds to do it, or intra-osseous – very hard in fresh baby, cord clamps x 2
- Equipment for cord blood gas sampling
- Disability – warming essential, towels to dry
- Drugs: Adrenaline: 10mcg/kg – usually 3kg so 30mcg IV as bolus
- Volume: N.Saline or O-Neg blood (if blood loss considered likely), 10-20ml/kg, can
repeat
Reference:
http://www.neoresus.org.au/pages/LM1-8-3.php
http://resus.org.au/guidelines/
Scroll down to neonatal resus section – you must download and read these guidelines!
4.1
High flow O2
Large bore IV access x 2 &Fluid bolus. 1-2 L crystalloid whilst arranging urgent O-negative
blood
Decompression left chest – 28-32Fr ICC underwater seal drain
Urgent Thoracic surgical consultation
Bedside US for possible tamponade
Fully expose for other stab wounds/injuries
4.2
Benefits
Sensitivity as good or better than CxR
Can diagnose tamponade
Limitations
View may be obscured by subcut emphysema, swelling/bruising, obesity
Operator dependent
4.3
> 1500ml blood in chest drain at insertion
> 200ml/h for 3 consecutive hours, or
> 100 ml/h for > 6 hours
Tamponade