saq 1 monash health practise exam 2014 2
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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)

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slide2

 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
Management
  • Those aspects of care of the patient encompassing
    • treatment
    • supportive care
    • disposition
slide4

Management

Treatment

Supportive care

Disposition

slide5

Management

Manage ABC / Resuscitation

Specific treatment

Supportive care / monitor progress

Manage complications

Communication

Consultation

Disposition

slide6

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

slide7

 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%)

slide8

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
 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 management1
 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
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
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
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
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
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
Communication & Consultation
  • Family/NOK
  • Inpatient specialties
    • If Listed in trauma call don’t need to repeat
  • Documentation
disposition
Disposition
  • OT then ICU
    • Is this enough detail?
disposition1
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
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
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