1. SAQ 1 Monash Health Practise Exam 2014.2

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%)

3. Management Those aspects of care of the patient encompassing – treatment – supportive care – disposition

4. Management Treatment Supportive care Disposition

5. Management Manage ABC / Resuscitation Specific treatment Supportive care / monitor progress Communication Consultation Manage complications Disposition

6. Management Manage ABC Resuscitation Specific treatment Supportive care / monitor progress Manage complications Communication / Consultation Disposition +/- Other Patient / Family / Medical consultation Label problem Degree of urgency +/- Criteria eg for ICU +/- Criteria for Rx Degree of urgency Key issues / opening statement +/- Goals of treatment

7. 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%)

8. 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

9. 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

10. 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) 2 0 to Shock 1 0 Head Injury/TBI (EDH SDH ICB)

11. 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?

12. 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

13. 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

14. 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?

15. 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

16. Communication & Consultation Family/NOK Inpatient specialties – If Listed in trauma call don’t need to repeat Documentation

17. Disposition OT then ICU – Is this enough detail?

18. 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

19. 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