□ Trauma is a major cause of morbidity and mortality in children and young adults.
□ Trauma care requires a multiprofessional team approach.
□ The primary survey recognises life-threatening 'ABCD' problems.
□ A rapid response to immediate life-threatening problems saves lives.
□ The top-to-toe secondary survey ensures that no injuries are missed.
□ The patient requires safe transfer for definitive care.
You are rostered to work in the emergency department resuscitation room. Ambulance control has informed the department that a casualty with multiple injuries will be arriving in approximately ten minutes. What preparations need to be made?
Members of the trauma team need to be alerted. The resuscitation room should always be ready to receive seriously injured patients. Team leaders should allocate tasks. Team members should don protective clothing.
A young female casualty arrives in the resuscitation room. She appears to be unconscious and looks extremely pale. She is snoring and breathing very fast. The left side of the chest is not moving. There is decreased air entry on the left side and it is hyper-resonant on percussion. Her right thigh looks swollen and deformed. The ambulance crew have already immobilised the casualty on a long spine board. She is wearing a cervical collar and her head is strapped between blocks. She is receiving oxygen.
What are the priorities in the care of the injured casualty?
A primary survey is performed using an ABCD approach. Life-threatening injuries are treated as they are identified.
• Airway with cervical spine control - the casualty is snoring. A jaw thrust is performed to avoid moving the cervical spine. The cervical spine is already immobilised using blocks and a hard collar (see Figure 14.1). High-flow oxygen is administered.
• Breathing - the patient is breathing very fast and has signs and symptoms of a left tension pneumothorax (see Table 14.2). This is treated by inserting a cannula in the left second intercostal space in the mid-clavicular line. This relives the tension pneumothorax. The circulation is assessed whilst preparing equipment to insert a chest drain on the left side.
The casualty's circulation is assessed and monitoring attached. She is very pale and has cool peripheries with a capillary refill time of three seconds. The paramedics have informed the team that her name is Penelope and that she fell off her horse. You are recording the observations: respiratory rate 30 breaths per minute, oxygen saturation 97% on 15 l/min oxygen, pulse 130 bpm, blood pressure 80/40 mmHg.
Can you explain these observations and what is the initial management?
Penelope has shock which is most likely to be due to bleeding causing hypovolaemia (see Table 14.3). The initial management includes obtaining intravenous access, sending blood for investigations, giving intravenous fluids and stopping any bleeding. There is an obvious right femoral fracture that could explain some of the blood loss.
The radiographer has taken chest and pelvic X-rays whilst resuscitation is ongoing. The chest drain has been inserted and can be seen on the chest X-ray. The pelvic X-ray shows a complex fracture which would explain the severity of the shock.
The orthopaedic surgeons stabilise the pelvic and femoral fractures in the resuscitation room as this will hopefully stop bleeding. The pelvic fracture is stabilised by applying an external fixator and the femoral fracture using a traction splint. Intravenous fluids (2000 ml warmed Hartmann's) are
Continued given to correct the circulating volume and Penelope's observations are now: pulse 110 bpm, blood pressure 90/50. Penelope also now seems to be moaning. You have been asked to assess and monitor her neurological status. What observations will you make?
You need to assess her neurological status using the Glasgow Coma Scale score. It is important to check she is moving all four limbs and that her pupils are normal.
Penelope may have a spinal injury and her back needs to be examined. How are we going to achieve this without further harming her and injuring ourselves?
We need to log roll Penelope to assess her spine. We first explain to Penelope what we are going to do. The technique used for the log roll is described above and in Figure 14.2.
Once Penelope has been stabilised in the resuscitation room she is transferred to the radiology department for further imaging studies. She is then taken to the high dependency unit. Later that evening she has successful surgery to fix her fractures. She spends four days on the high dependency unit and a further five weeks in hospital recovering from her injuries. Six months later she is still having physiotherapy. She has missed her final term at university and is not working. Her accident has had a long-term impact on her social, psychological and physical well-being.
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