Jason Wolfe's ATLS Trauma Moulage Page

(Thoughts on the Management of the Multiply Injured Patient)

Aim :

To give people a framework for thinking about the management of the traumatised patient and assist them to pass the AT ! trauma moulage" This webpage was produ#ed as a #ulmination of the tea#hing and e$perien#es I gained during a past AT ! #ourse" The AT ! #ourse itself is an e$#ellent way of pra#ti#ing the theoreti#al and pra#ti#al aspe#ts of trauma management" I highly re#ommend anyone involved in management of trauma patients to do it" This is not meant as a short #ut whi#h negates the need to read the AT ! #ourse manual" %ou are reminded that it is e$tremely unlikely that you will pass the #ourse if you don&t read the AT ! manual" 'ote that the term &AT !& is a registered trade mark of the &Ameri#an (ollege of !urgeons&" This web)page is not affiliated to* nor offi#ially endorsed by them"

ATLS: Note : PS:

General Principles of Trauma Management

1. $. &. *. T ere is a nee! for rapi! e"aluation of t e trauma patient. Time #aste! costs li"es. T e a%sence of a !efiniti"e !iagnosis s oul! ne"er impe!e t e application of essential treatment. T e first 'Gol!en 'our' is crucial to %ot t e s ort an! long term sur"i"al of t e patient. (t also is also critical in !etermining t e mor%i!it) t at t e patient #ill en!ure. T ere is a nee! to esta%lis management priorities: T e t ings # ic #ill +ill t e patient first are al#a)s t e t ings # ic s oul! %e c ec+e! an! treate! first. T ings # ic #ill +ill t e patient later are manage! later. T us, air#a) pro%lems are manage! an! treate! %efore %reat ing pro%lems, # ic in turn are treate! %efore circulator) pro%lems.

-.

All treatment modalities should be governed by the abiding prin#iple of &+irst do no harm&"

."er"ie# of ATLS Protocol :/

0Stages 1 Su%2ect 'ea!ings3

1. $. &. *. -. 9. :. ;.

Preparation Triage Primar) Sur"e) 0A45673 1 8esuscitation A!2uncts to Primar) Sur"e) 1 8esuscitation 5onsi!er nee! for Patient Transfer Secon!ar) Sur"e) 0#it AMPL7 'istor)3 5ontinue! Post/8esuscitation Monitoring 1 8e/e"aluation

Transfer to ,efinitive (are

1. Preparation / 7<uipment nee!e! for Practice

=ou s oul! familiarise )ourself #it all t e follo#ing e<uipment. =ou s oul! %e a%le e>plain eac item's use, not onl) 2ust %) p )sical !emonstration %ut also %) "er%al !escription.

G7N78AL 7?@(PM7NT

-ne ive Patient (usually an a#tor with #opious but e$pert make)up to ensure realism) -ne 'urse Assistant (who usually is an ine$perien#ed student) -ne (andidate (with large amounts of adrenaline in blood stream and suitably fast beating heart) -ne .$aminer (to make life diffi#ult and generally throw a spanner in the works) /niversal Pre#autions Toilet 01) (igarette for afterwards

578A(5AL SP(N7 7?@(PM7NT

ong !pinal 2oard 3ard (ollars of various si4es !andbags Tape for se#uring head

A(8WA= 7?@(PM7NT

!u#tion -$ygen 5entilator aryngos#opes (various si4es 6 shapes) 2ag and Mask with 7eservoir +le$ible 2ougie Tongue ,epressor

-ropharyngeal 1 'asopharyngeal Tubes -rotra#heal 1 'asotra#heal 1 .ndotra#heal Tubes 'eedle (ri#othyroidotomy !et +ormal (ri#othyroidotomy !et Tra#heostomy set (for #hildren under 89 yrs) !urgi#al ,rapes 8:ml !yringes !#alpel

487AT'(NG 7?@(PM7NT

!tethos#ope arge 2ore (annula (hest ,rain !et in#luding ;) o Antisepti# swap o o#al Anaestheti# o !#alpel o ,isse#ting for#eps o (hest ,rain o Tubing o !uitable #ontainer with underwater seal o !tit#h Material o -##lusive dressing

5(85@LAT(.N 7?@(PM7NT

Pressure ,ressings 6 !wabs Antisepti# swaps 3ypodermi# 'eedles Intra)venous (annulas ong)venous (annulas for use with !eldingers Te#hni<ue Peri#ardio#entesis over)the)needle #annulas 5enous (ut)down set Peritoneal ,ialysis (atheter Adhesive Tape =iving sets !yringes >armed (rystalloid 1 (olloid 1 2lood PA!= ; Pneumati# Anti)!ho#k =arment

68@GS

!et of 7esus#itation Trolley ,rugs igno#aine (01) Adrenaline) 1A Inje#tion igno#aine =el for (atheterisation

?ylo#aine !pray for -ro 1 'asopharyngeal 1A 3eparin

M(S57LLAN7.@S ST@BB

7esus#itation trolley ,efibrillator Pulse -$imeter 2lood Pressure Monitor (ardia# Monitor (apnograph 'ormal 6 ow)7ange Thermometers 'asogastri# Tube /rinary (atheter +ast Intravenous Infuser 1 >armer ,evi#e -phthalmos#ope 6 -tos#ope +ra#ture !plints =lasgow (oma !#ale (hart 2roselow Paediatri# 7esus#itation Measuring Tape ?)7ay 5iewing 2o$ >arming 2lanket Polaroid (amera 3ammer 6 'ails to prevent the paramedi#s who brought the patient in from leaving the department before they have given an ample history"

$. Triage.
Triage is t e prioritisation or ran+ing of patients accor!ing to %ot t eir clinical nee! an! t e a"aila%le resources to pro"i!e treatment. T e process is %ase! on t e same A45 principles as e>plaine! %elo#.

&. Summar) of Primar) Sur"e) 1 8esuscitation :/

07>plaine! in full !etail later3

A 4 5 6 7

/ / / / /

Air#a) 1 5er"ical Spine 5ontrol 4reat ing 1 .>)genation 5irculation 1 'aemorr age 5ontrol 6)sfunction 1 6isa%ilit) of t e 5NS 7>posure 1 7n"ironmental 5ontrol

*. A!2uncts to Primar) Sur"e) 1 8esuscitation :/

T ese are "arious useful monitoring or t erapeutic mo!alities # ic supplement t e information alrea!) o%taine! using clinical s+ills in t e Primar) Sur"e).

T e) inclu!e :/
8" 9" @" A" B" C" D" Pulse -$imeter 2lood Pressure (ardia# Monitor 1 .le#tro#ardiogram Arterial 2lood =ases 1 .nd Tidal p(-9 ?)7ays ) (hest ?)7ay 1 (ervi#al !pine 1 Pelvis 1 -thers 'asogastri# Tube 6 /rinary (atheter (ore Temperature

-. 5onsi!er t e Nee! for 7mergenc) Patient Transfer.

T e particular acci!ent unit or ospital # ere t e patient as arri"e! is not al#a)s t e most suita%le place for t e !efiniti"e care of t at patient to %e manage!. .nce t e resuscitation is #ell un!er #a) an! t e patient is sta%le, consi!eration s oul! %e gi"en to transferring t e patient else# ere. Transfer ma) %e to anot er ospital # ic is more geare! to treating t e multipl) in2ure! patient 0eg. a le"el 1 trauma centre3 or to anot er facilit) # ic can a!e<uatel) !eal #it t e particular set of specialise! in2uries # ic are peculiar to )our patient 0eg. a neurosurgical unit3. Transfer ma) also %e to a !ifferent !epartment of t e same ospital 0eg. t eatres C ra!iolog)3. (n an) case, patient transfer is often t e time of greatest peril for t e patient %ecause it is all too eas) for t e 'le"el of care' to !ecline. T e c allenge t erefore is to ensure t at t is le"el of care !oes not !eteriorate at an) time. Transfer s oul! al#a)s %e as soon a possi%le after t e patient is sta%ilise!. T e ac<uiring of specialise! in"estigations s oul! not ol! up t e transfer of t e patient as t ese in"estigations are often more appropriatel) performe! in t e unit # ere t e patient is to %e transferre!.

9. Secon!ar) Sur"e).

A full AMPL7 istor) is ta+en from an)one # o +no#s t e rele"ant !etails. T is often inclu!es %ot t e famil) an! t e parame!ics # o %roug t t e patient in. T is is follo#e! %) complete ea! to toe 1 s)stems e>amination. All clinical, la%orator) 1 ra!iological information is assimilate! an! a management plan is formulate! for t e patient. 6uring t is time t ere is a process of continue! post/resuscitation monitoring 1 re/ e"aluation. An) su!!en !eterioration in t e patient s oul! imme!iatel) prompt t e !octor to return to t e primar) sur"e) for a re/assesment of t e A4567's.

AMPL7 'istor) :/
A / Allergies M / Me!icines P / Past Me!ical 'istor) C Pregnanc) L / Last Meal 7 / 7"ents C 7n"ironment lea!ing to t e current trauma

:. Transfer to 6efiniti"e 5are

T is is go"erne! %) t e same principles as #ere mentione! a%o"e in t e emergenc) transfer of patients. T e le"el of care s oul! not !eteriorate.

T e Primar) Sur"e) 1 8esuscitation.

0T is is t e main part # ic is teste! in t e practical moulages, so t is t e part #ill %e co"ere! in t e greatest !etail3

N.T7 B(8ST :/ D (mme!iatel) Life T reatening (n2uries or 5on!itions # ic s oul! %e pic+e! up in A4567 an! treate! imme!iatel) :/

8" 9" @" A" B" C" D" E" F"

Inade<uate Airway Prote#tion Airway -bstru#tion Tension Pneumothora$ -pen pneumothora$ +lail (hest with 3ypo$ia Massive 3aemothora$ (ardia# Tamponade !evere 3ypothermia !evere !ho#k from 3aemorrhage /nresponsive to +luid 7esus#itation"

N.T7 ALS. :/ 1& Potentiall) Life T reatening ENon/.%"iousE (n2uries # ic s oul! %e consi!ere! in t e traumatise! patient, %ut # ose management can often #ait until after A4567 until t e time of !efiniti"e care :/
8" 9" @" A" B" C" D" E" F" 8:" 88" 89" 8@" !imple Pneumothora$ 3aemothora$ Pulmonary (ontusion Tra#heo)2ron#hial Injury 2lunt (ardia# Injury Traumati# Aorti# ,isruption ,iaphragmati# 7upture Mediastinal Traversing >ounds 2lunt -esophageal Trauma !ternal 1 !#apular 1 7ib +ra#tures 7uptured iver or !pleen 7upture of an abdominal or pelvi# vis#us Any other #hest 1 abdominal 1 or pelvi# injuries whi#h have resulted in organ damage but not in immediate sho#k

'o# to approac t e Primar) Sur"e) an! # at to !o :/

T is ne>t section assumes )ou are in a moulage scenario an! goes t roug )our possi%le actions an! reactions in response to # at )ou fin! #it )our patient.

A / A(8WA= 1 578A(5AL SP(N7 5.NT8.L

!ay you are wearing universal pre#autions" Approa#h patient from head side and stabilise #ervi#al spine using in)line immobilisation" Try to avoid pla#ing your hands over the patient&s ears" Introdu#e yourself and reassure patient" Assess preliminary A2( from patients response to this" I+ T3. AI7>A% I! '-T AT .A!T PA7TIA % !.(/7.* then definitive #ervi#al spine #ontrol will have to wait" Ask the nurse to take over the fun#tion of in)line immobilisation of the #ervi#al spine* and M-5. -'T- AI7>A% MA'A=.M.'T" ,on&t forget to #ome ba#k to #ervi#al spine management later" (.75I(A !PI'. MA'A=.M.'T ;) Ask for a hard ne#k #ollar" Measure the si4e of #ollar by measuring from the angle of mandible to the top of shoulder 1 trape4ius" The #ollar should be the same si4e from the bla#k marker peg to the base of the hard part of the #ollar" Apply !andbags and Tape" AI7>A% MA'A=.M.'T ;) In the trauma patient* if the patient is likely to need intubation eventually* then early intubation is preferred* so as to prevent the patient from tiring and be#oming a#idoti#" !u#tion out the airway or remove foreign bodies if ne#essary" I+ ) 27.AT3I'= I! !P-'TA'.-/! A', T3. PATI.'T I! (-'!(I-/!* 2/T AI7>A% I! (-MP7-MI!., 2% P--7 P3A7%'=.A T-'. 1 7.,/(., .5. -+ (-'!(I-/!'.!! (=(! F)8@) ;) o Try jaw thrust 1 #hin lift and ask for response" o If the response is good* insert an oropharyngeal (=uedel) or nasopharyngeal airway" o 'otes ;) The oropharyngeal airway is measured from the edge of the mouth to the tragus of the ear" The nasopharyngeal airway is measured from the nostril to the tragus of the ear" Its diameter is also #onveniently estimated by looking at the patient&s little finger" ,on&t attempt to insert a nasopharyngeal airway if the patient has a head injury with the possibility of a basal skull fra#ture" o Assuming the patient responds to this* apply o$ygen using a fa#e mask with atta#hed reservoir bag" o If you haven&t already done so* most patients should now have their ne#k immobilised with a hard ne#k #ollar* sandbags and tape" I+ ) T3. !/PP-7TI5. M.A!/7.! A2-5. 3A5. +AI .,* -7 I+ PATI.'T I! /'(-'!(I-/! >IT3 A =(! -+ E -7 .!!* -7 I+ T3. PATI.'T I! AP'-.I( ;)

o o o o

The patient needs a definitive airway" (all for an anaesthetist" If the patient is (-MP .T. % /'7.!P-'!I5.* it is ne#essary to pro#eed straight to endotra#heal intubation" Method of .',-T7A(3.A I'T/2ATI-'" Pre)o$ygenate with bag and mask" The ne#k #ollar will need to be removed during intubation and during this time your assistant must provide in)line immobilisation of the ne#k" !tanding above the head of the patient* insert a laryngos#ope into the oropharyn$* pushing the tongue to the left" Pull the s#ope upwards and away from yourself until the vo#al #hords be#ome visible" !lip the endotra#heal tube through the vo#al #hords* if ne#essary using a gum elasti# bougie" Inflate the tube&s balloon seal and #onne#t the tube to a reservoired &bag 6 mask& or ventilator" !ome patients may be suffiently stable with the .T tube in situ to breathe spontaneously without the need for bag 6 mask or ventilator" .nsure positioning of tube in tra#hea by listening to the #hest (listen to the lung api#es* bases and over the stoma#h)" +inal #onfirmation #an be made by #onne#ting the tube to a #apnograph" !e#ure the tube using a #ommer#ially available .T tube se#uring devi#e" -n#e finished* re)establish #ervi#al spine #ontrol using the hard ne#k #ollar* sand)bags and tape" If the patient is !TI PA7TIA % (-'!(I-/! A', 7.!P-'!I5.* then intubation will need to be #arried out by &7API, !.G/.'(. I',/(TI-'&* using anaestheti# drugs" The pro#edure should only be #arried out by pra#titioners who are <uite familiar with its &ins and outs& (whi#h usually e$#ludes everyone e$#ept e$perien#ed anaesthetists)" If you aren&t e$perien#ed enough to perform 7!I* then &bag 6 mask& until the anaesthetist arrives"

I+ ) T3. A(TI5. M.A!/7.! A2-5. 3A5. +AI .,* -7 T3.7. I! PA7TIA /PP.7 AI7>A% -2!T7/(TI-' >IT3 !T7I,-7* -7 T3. PATI.'T I! AP'-.I( +7-M (-MP .T. AI7>A% -2!T7/(TI-' ;) o Perform '.., . (7I(-T3%7-I,-T-M% and des#ribe this method" o A large bore #annula is inserted through the #ri#o)thyroid membrane and is then #onne#ted to high flow o$ygen at 8B litres 1 minute" Inspiration 1 .$piration is a#hieved by intermittently holding ones thumb over the side of an open %)#onne#tor atta#hed to the #annula ) 8 se#ond inspiration* A se#onds e$piration" The patient #an only be ade<uately o$ygenated using this method for about @: ) AB minutes" o (all for an anaesthetist"

+inally establish definitive airway by formal #ri#othyroidotomy and des#ribe this method"

-T3.7 I',I(ATI-'! +-7 A ,.+I'ITI5. AI7>A% I'( /,. ;) o !evere ma$illofa#ial 1 laryngeal 1 ne#k injuries with impending obstru#tion" The patient will almost #ertainly re<uire a surgi#al airway" o !evere (losed 3ead Injuries with a redu#ed level of #ons#iousness* a risk of aspiration* and the need for hyperventilation"

If you haven&t already done so* apply 8::H o$ygen" Ask nurse to apply Pulse -$imeter* 2lood Pressure Monitor and (ardia# Monitor" Ask her to take readings from all these monitors"

4 / 487AT'(NG 1 .F=G7NAT(.N

If patient suddenly deteriorates at any point* move ba#k and #he#k airway again" Move down ne#k" Assess (arotid pulse for 7ate* (hara#ter 6 5olume" (he#k 'e#k veins for distension" (he#k for >ounds* aryngeal #repitus 6 !ub#utaneous emphysema" (he#k if Tra#hea is #entral" Then move onto #hest" Inspe#t for 2ruising 1 Asymmetry of e$pansion" Palpate any areas of interest" (he#k for !ub#utaneous emphysema and +lail #hest" Per#uss and Aus#ultate both anterior and lateral #hest and ask for results" I+ ) PATI.'T 3A! A !IMP . P3./M-T3-7A? ;) o 3yper)resonant #hest* redu#ed 1 absent breath sounds* but ne#k veins down and tra#hea #entral" o Ask the nurse to set up formal (hest ,rain set" o ,on&t insert the #hest drain yet* but state that you intend to insert it later" o (3.!T ,7AI' I'!.7TI-' ;) ,rape 6 surgi#ally prepare the #hest" If there is time* give an inje#tion of ligno#aine lo#al anaestheti#" Make an in#ision in the Bth inter#ostal spa#e just anterior to the mid)a$illary line* and just above the upper border of the Cth rib" 2lunt disse#t down through the inter#ostal mus#les* until the pleura is pun#tured" (lear away adhesions* #lots or foreign bodies using a finger sweep"

(lamp the pro$imal end of the #hest drain and then advan#e it into the #hest to the desired length" (onne#t the #hest drain to an underwater)seal apparatus and then un#lamp it" (he#k the drain is fun#tioning #orre#tly ) the water #olumn at the underwater)seal apparatus should move up on inspiration and bubble during e$piration" !uture the tube in pla#e using a purse)string suture and then apply an adhesive non)gas)permeable dressing to the site" Apply the dressing to @ out of A sides of the drain tube" +inally re)e$amine the #hest and obtain an early #hest $)ray"

I+ ) '.(I 5.I'! ,I AT.,* T7A(3.A ,.5IAT.,* A2!.'T -7 7.,/(., 27.AT3 !-/',! A', (3.!T 3%P.7)7.!-'A'T* T3.' T3I'I &T.'!I-' P'./M-T3-7A?& ;) o Ask nurse to set up formal (hest ,rain set" o In the meantime* perform 'eedle Thora#ostomy and #he#k for hissing sound" eave the needle thora#ostomy open" o 7e)e$amine #hest and ask for response" o If patient stabilises* then leave formal #hest drain until later" o If they don&t stabilise* perform another 'eedle Thora#ostomy and pro#eed straight to formal (hest ,rain insertion" o ,es#ribe this method"

I+ ) PATI.'T 3A! .5I,.'(. -+ (3.!T T7A/MA* ,I AT., '.(I 5.I'!* M/++ ., 3.A7T !-/',!* A', ,.(7.A!., A7T.7IA 2 --, P7.!!/7. (P-!!I2 % .5.' P/ !. .!! . .(T7I(A A(TI5IT%) (2.(I&s T7IA,)* T3.' T3I'I &P.7I(A7,IA TAMP-'A,.& ;) o Pro#eed straight to 'eedle Peri#ardio#entesis" o ,es#ribe this method and #he#k for response" o '.., . P.7I(A7,I-(.'T.!I! ;) Monitor the patient&s vital signs and .(= before* during 6 after the pro#edure" ,rape 6 surgi#ally prepare the $iphoid area" /se a J8C gauge 8B#m needle* @ way tap* and a 9:#m syringe" Pun#ture the skin 8 ) 9#m below and lateral to the left $iphi) #hondral jun#tion* pointing the needle at an angle ABK to the skin and aiming for the tip of the left s#apula" Advan#e the needle until there is a flush)ba#k of blood* and at this point withdraw as mu#h blood as possible"

If the needle is advan#ed so that it penetrates the myo#ardium* the .(= pattern will #hange* produ#ing wild !T)T segment variation and widened 1 enlarged G7! #omple$es" If this o##urs* the needle should be withdrawn slightly until the .(= pattern returns to normal" It is sometimes ne#essary to leave a #annula in situ for repeat aspirations* and so here the needle may be #hanged to a plasti# #annula using the !eldinger te#hni<ue"

I+ ) PATI.'T I! 3%P-?I(* !3-(I.,* 3A! A !T-'% ,/ (3.!T* A2!.'T 27.AT3 !-/',! A', A T7A(3.A ,.5IAT., A>A% +7-M T3I! !I,.* T3.' T3I'I &MA!!I5. 3A.M-T3-7A?& ;) o .stablish intravenous a##ess using two large bore #annulas" o Pro#eed immediately to insertion of #hest drain"

I+ ) PATI.'T 3A! A + AI (3.!T A', I! 3%P-?I( ;) o .arly intubation is essential" o Perform -rotra#heal intubation yourself preferably by &7apid !e<uen#e Indu#tion& or #all for an anaesthetist to do it"

I+ ) PATI.'T 3A! A' -P.' P'./M-T3-7A? ;) o (over this opening with an o##lusive dressing" o !e#ure the dressing well so as to prevent air)leaks" o Pro#eed straight to (hest ,rain* pla#ing the drain well away from the wound of the original open pneumothora$"

5 / 5(85@LAT(.N 1 'A7M.88'AG7 5.NT8.L

Ask nurse to repeat measurements of -$ygen !aturation* 2lood Pressure 6 Pulse" Palpate the patients head and hands looking for signs of &sho#k&" This is defined as insuffi#ient organ perfusion and o$ygenation" It is suspe#ted in a patient with #old* #lammy* pale* peripherally shut down e$tremities" Move onto Abdomen 6 Pelvis" A2,-M.' ;) o Inspe#t abdomen for injuries or distension"

o o o o

Palpate abdomen for any masses or signs of peritonism" (onsider abdominal per#ussion 6 aus#ultation" If there are signs of abdominal bleeding* ask the nurse to fast bleep the on) #all surgeon and ask them to #ome to #asualty" Ask the nurse to state that you have a #lini#ally sho#ked patient in #asualty who you suspe#t has abdominal bleeding* who you are in the pro#ess of resus#itating* but who may urgently need to be taken to theatre for laparotomy"

P. 5I! ;) o Palpate the Pelvis" o Apply both lateral and antero)posterior springing for#es onto the anterior superior ilia# spines and feel for abnormal mobility or #repitus" -nly perform this e$amination on#e" o Ask e$aminer whether the pelvis is stable or unstable" o If there are signs of a fra#tured pelvis* ask the nurse to fast bleep the orthopaedi# surgeon on #all and ask them to #ome to #asualty" o Ask the nurse to state that you have a #lini#ally sho#ked patient in #asualty who you suspe#t has an unstable fra#ture of the pelvis* who you are in the pro#ess of resus#itating* but who re<uires urgent stabilisation with a pelvi# e$ternal fi$ator" o =ive #onsideration to the use of a PA!= Pneumati# Anti)!ho#k =arment or internally rotate the hips (whi#h may #lose an unstable open)book pelvi# fra#ture and limit the bleeding)" o Try to get a pelvis $)ray before the orthopaedi# surgeon arrives* provided this doesn&t interfere with the rest of your resus#itation"

IM2! ;) o Gui#kly move onto the limbs* #utting off #lothes as ne#essary* and e$amining for the presen#e of obvious deformity or soft tissue haematoma" o Any sour#es of e$ternal haemorrhage should immediately be stemmed by applying dire#t pressure and wrapping in a bandage" o If there are -pen ((ompound) +ra#tures* then these should be photographed* and then immediately pa#ked with a 2etadine soaked bandage and dire#t pressure applied" Ask the nurse to stand by with intravenous morphine* a tetanus inje#tion and intravenous antibioti#s (usually #efuro$ime 6 metronida4ole)" The orthopaedi# team should be informed and asked to attend the A6. department"

+ /I, 7.!/!(ITATI-' ;) o 3aving e$amined the body for potential sour#es of haemorrhage as well as stemming any areas of overt haemorrhage* fluid resus#itation should begin in earnest" o %ou need to pla#e two large bore (J8A gauge) intravenous #annulas* one in ea#h #ubital fossa" o 2lood should be aspirated into a syringe for +2(* /6.* and (ross) Mat#h" Ask the nurse to ensure that the sample is rushed to the lab" Ask for 9 ) A units of - 'egative 2lood* 9 ) A units of Type !pe#ifi# 2lood* and 9 ) A units of (rossmat#hed 2lood* depending on the individual #ir#umstan#es" o If #annulation is unsu##essful* then alternatives in#lude the other #ubital fossa* the femoral vein* the sub#lavian vein* the e$ternal jugular vein* the internal jugular vein* or a venous #ut)down for the great saphenous vein" o Immediately set up 8 litre of warmed 3artmanns for ea#h of the two #annulas and run through using a fast infuser" This #an take 8 ) 9 minutes to run in" o In #hildren under C years* intra)osseous infusion is the preferred method of a##ess after 9 unsu##essful attempts at #annulation" In infants* s#alp veins may be tried* and in neonates the umbili#al vein often provides e$#ellent a##ess" The volume of the infusion bolus in #hildren is 9:mls 1 kg and this #an be repeated 9 or @ times depending on response" o Ask the nurse to repeat -$ygen !aturation* 2lood Pressure* Pulse 6 7espiratory 7ate" (he#k also the Temperature" o A##ording to response* B::mls of #olloid #an then be infused through ea#h #annula* or (more likely) in the absen#e of a #lini#al improvement* the 9 units of - 'egative blood whi#h have just arrived from the lab should be given using the fast infuser" If the patient #an wait 8: minutes for type spe#ifi# blood* then this is preferable"

(he#k for (lini#al 7esponse"

(f t e patient fails to respon!, or initiall) respon!s %ut su%se<uentl) !eteriorates, )ou s oul! reflect on t e "arious possi%le causes of t is state of affairs :/
8" 9" =o ba#k and #he#k Airway 6 2reathing" The patient #ould be 2 ..,I'= faster than you are repla#ing blood" These patients need to be taken to theatre immediately for surgi#al repair of the injured organ or vessel"

@" A" B"

C"

D"

The patient #ould be 3%P-T3.7MI( and therefore may be responding more slowly than a normothermi# patient" The patient #ould be in (A7,I-=.'I( !3-(I; 3ere the heart pump is failing due to blunt trauma* or sometimes due to penetrating trauma" (onsider again peri#ardial tamponade and a#t appropriately if re<uired" (onsider early (5P monitoring" The patient may be P7.='A'T" If moderately or heavily pregnant women are treated in the supine position* the bulky uterus may impede the flow of blood in the Inferior 5ena (ava" !u#h patients should be bolstered so that they are lying slightly on their left side by pla#ing sand)bags or pillows under the right side of the pelvis and #hest" This manoeuvre should be #arried out earlier rather than later in the resus#itation" The patient may be in './7-=.'I( !3-(I; This o##urs with spinal #ord injuries in whi#h the sympatheti# outflow is damaged" This denervation of the heart and blood vessels results in a #lini#al pi#ture of hypotension without ta#hy#ardia or peripheral vaso#onstri#tion" 5olume resus#itation is still the primary treatment* but #onsideration should be given to the judi#ious use of vasopressors" .arly (5P monitoring 6 !wan)=an4 pulmonary artery #atheterisation may also be useful" !.PTI( !3-(I; This is un#ommon in the early period following trauma but may o##ur in penetrating abdominal injuries with a perforated vis#us or in other penetrating injuries where the wound has been #ontaminated with dirty e$ogenous debris* espe#ially if arrival in A6. has been delayed for hours or days" It is identified by the presen#e of hypotension* ta#hy#ardia* pyre$ia and #utaneous vasodilation"

All t e a%o"e are treate! %) generous "olume replacement along #it !efiniti"e treatment of t e cause of t e s oc+.

.t er 5onsi!erations in t e 6iagnosis 1 Treatment of S oc+.

8" - , A=. ) .lderly patients have less &physiologi#al reserve&; They are less able to in#rease heart rate and stroke volume in response to sho#k" 5ital organs are more sensitive to the de#reased blood flow and hypo$ia asso#iated with sho#k" The lungs are less effi#ient at the gaseous e$#hange of o$ygen" The kidney is less able to respond to the volume preserving stimulus of the stress hormones Aldosterone* Anti) ,iureti# 3ormone 6 (ortisol" All these fa#ts #ontribute to its in#reased morbidity and mortality" It is thus even more #ru#ial in the elderly patient to pay meti#ulous attention to volume resus#itation* and the pla#ement of arterial and (5P invasive monitoring devi#es will greatly assist in its assessment" These devi#es should be pla#ed earlier rather than later" %-/'= A=. ) (hildren and babies have an espe#ially high physiologi#al reserve" 3omeostati# me#hanisms maintain blood pressure and #ardia# output despite the loss of large per#entages of their blood volume" 3owever when the

9"

@"

A"

B"

C"

per#entage of blood loss gets to about A:H ((lass I5 haemorrhage)* the blood pressure and #ardia# output drop pre#ipitously" The lesson here is that #hildren may still have normal vital observations despite being in a high level of sho#k" Always take advi#e from a paediatri#ian early" AT3 .T.! ) Althletes may have an in#reased blood volume of up to 8B ) 9:H* stroke volume #an in#rease by B:H* #ardia# output #an in#rease by C::H and resting pulse is generally lower than unfit individuals" These fa#ts mean that the usual #lini#al signs of hypovolaemia may not be manifested in athletes* even though signifi#ant blood loss may have o##urred" P7.='A'(% ) >omen have a higher plasma volume during pregnan#y" (ardia# output in#reases by 8": ) 8"B litres 1 minute* and heart rate in#reases by 8: ) 8B beats 1 minute" Minute ventilation in#reases also (primarily due to an in#rease in the respiratory tidal volume)* and the 7enal =lomerular +iltration 7ate also in#reases" All these things in#rease the physiologi#al reserve of the mother and mean that signs of hypovolaemia appear later" The physiologi#al responses to sho#k will always favour the mother* and whereas even in moderate sho#k* the mother may be <uite well* the foetus may a#tually be in severe sho#k* deprived of the majority of its perfusion" Invasive maternal monitoring and foetal #ardioto#ographi# monitoring are often re<uired at an early stage to minimise #ompli#ations to both mother and foetus" Always take advi#e from an obstetri#ian early" ,7/=! ) 5arious drugs #an affe#t the body&s response to stress" 2eta) blo#kers prevent the ta#hy#ardia and in#reased sympatheti# responses to sho#k and may #onfuse the #lini#al pi#ture" ,iureti# use #auses a relative hypovolaemia whi#h may impair the body&s reserve to respond to stress" 3.A, I'L/7I.! ) The brain has a very high demand for o$ygen and so se#ondary brain damage will o##ur very <ui#kly if the brain is deprived of its supply of o$ygenated blood" The (erebral Perfusion Pressure is e<ual to the Mean Arterial 2lood Pressure minus the Intra)(ranial Pressure" Thus* brain perfusion is redu#ed either by a de#rease in blood pressure* or by an in#rease in intra)#ranial pressure" 3ead injuries may in#rease intra)#ranial pressure by the presen#e of mass) lesions (haematoma) preventing the free #ir#ulation of #erebro)spinal fluid" !ub) ara#hnoid haemorrhage in#reases intra)#ranial pressure be#ause the blood in the #erebro)spinal fluid blo#ks the ara#hnoid granulations and thereby stops the (!+ from being reabsorbed ba#k into the venous system" There are a number of #onfli#ting pro#esses in the head injured patient that make it essential to treat sho#k and hypovolaemia in a very pre#ise manner" -ver #autious volume resus#itation will result in hypotension wheras over enthusiasti# volume resus#itation will result in volume overload whi#h may e$a#erbate an already pre#arious intra)#ranial pressure" The key aspe#ts in the optimal management of the head injured patient in#lude ; early invasive monitoring to assist in a##urate volume resus#itation* early endotra#heal intubation to assist with hyperventilation* and early #onsultation with an e$perien#ed neurosurgeon"

6 / 6=SB@N5T(.N 1 6(SA4(L(T= .B T'7 5NS

An AAP@ or G5S assessment is carrie! out. T e patient's pupils are e>amine! for siGe, s)mmetr) 1 reaction to lig t. T e consensual pupillar) refle> can also %e teste! ere.

AAP@ Assessment :/
A A P @ / / / / Alert 8espon!ing to Aoice 8espon!ing to Pain @nresponsi"e

Glasgo# 5oma Scale 0G5S3 :/

7)e .pening * / Spontaneous & / To Speec $ / To Pain 1 / No 7)e .pening 4est Aer%al 8esponse - / .rientate! * / 5onfuse! 5on"ersation & / (nappropriate Wor!s $ / (ncompre ensi%le Soun!s 1 / No 8esponse 4est Motor 8esponse 9 / .%e)s comman!s - / Appropriate localising response to pain * / Wit !ra#al response & / A%normal fle>ion response 06ecorticate 8igi!it)3 $ / 7>tension response 06ecere%rate rigi!it)3 1 / No 8esponse

7 / 7FP.S@87 1 7NA(8.NM7NTAL 5.NT8.L

3ere* any #lothes whi#h haven&t already gone are removed" (are is still taken to prote#t all areas of the spine from undue movement" +inally* the patient is #overed with a blanket or other suitable warm #overing to prevent hypothermia"

3ere endeth the lesson MM