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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SAQ 1 Monash Health Practise Exam 2014.2

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Saq 1 monash health practise exam 2014 2

SAQ 1Monash Health Practise Exam 2014.2


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

Management

  • Those aspects of care of the patient encompassing

    • treatment

    • supportive care

    • disposition


Saq 1 monash health practise exam 2014 2

Management

Treatment

Supportive care

Disposition


Saq 1 monash health practise exam 2014 2

Management

Manage ABC / Resuscitation

Specific treatment

Supportive care / monitor progress

Manage complications

Communication

Consultation

Disposition


Saq 1 monash health practise exam 2014 2

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


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%)


Saq 1 monash health practise exam 2014 2

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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