 Ambulance team en route to ED with trauma

patient.
 Call ED for further instruction :
◦ Patient male, 25yo, with motor cycle accident 30 minute
prior. Helmet +, speed 60 kmh, passed out (-),
vomitting (-).
◦ Primary Survey : Instruction :
• A : Patent • Cervical Collar
• B : Symmetrical Movement, RR • Supplemental 02 NRBM 10 L/min
28x/min SpO2 96% Room Air • 2 large bore IV
• cold and dry acral, thready pulse, • Challenge RL 250cc > evaluate
regularly regular. BP 78/50. HR vital sign / 5min
120x/min. T:: 36,7 C • Tranexamid Acid 1g
• D : GCS : E4V5M6 • Blood sample

◦ ETA 15 min to ER
 Trauma Team Activation

2 2
 A :Clear
 B : Symmetric,  RL 250cc > evaluate
spontaneous, 28 x/m
SaO2 99% (NRBM 15 vital sign
lpm)  Blood cross match
 C : cold and dry acral, BP  Order 2 unit PRC + 2
: 75/48 mmHg, HR : 128
bpm, thready unit FFP
pulse,regular, T: 37 °C
 D : GCS E4V5M6
 E : Undres Px, Warm
blanket +

Call Surgery Dept

3
 AMPLE History unremarkable
 General appearance: looks severely ill, GCS 456
 Head and neck :
pale (-), anemic conjunctiva (+/+), cyanotic (-), JV flat, dry mouth
and tongue, laceration (-), crepitation (-), bruising (-), swelling (-),
Blood/CSF (-).
 Neuro : Repeat GCS 456, Motor Function 5/5, sensation +/+,
reflexes ++/++
 Cardiovascular :
S1 S2 regularly regular, rubs (-), gallops (-) , murmurs (-)
 lungs : symmetric movement, retraction (-), laceration (-),
crepitation (-), bruising (-)
 Abdomen VBS Rales Wheezi
tender (+), BS (+), Laceration (+) ng
 Pelvis : laceration (-), crepitation (-), Compression
+ test
+ (-)
- - - -
 Limb
◦ Look: deformity(-), bruising (-), laceration (-) + + - - - -
◦ Feel: tenderness (-), distal pulses (+)
◦ Movement : active ROM (+) & + + - - - -
 Log Roll : unremarkable sensation
4 4
 E-FAST
Lung Scan (D) Lung Scan (S)

PLAPS Point (S)

PLAPS Point (D)

IVC < 1,5cm Subxiphoid Cardiac Window

FREE FLUID IN MORRISON POUCH

Splenorenal window

Suprapubic window
 Hipovolemic shoct dt Blunt Abdominal Injury
 LAB :
CBC,SGOT/SGPT,UR/CR,Electrolyte,HF,BGA
 PRC 1 unit > BP 70/46, HR 130x/min, cold
and dry acral
 Surgery dept +
 30 min > go to OR
 Direct pressure for Any compressible vessel (Control
Hemmorhage)
 Tourniquet as needed
 IV / IO access
 Hypotensive resuscitation with crytalloid to maintain
mentation and/or SBP of 80mmHg
 Rapid transfer for definitive control of hemorrhage
(“Scoop and Run”)
 Activation of trauma team
◦ On or prior to arrival
◦ EP/Surgeon/Anesthesologist/OR/ICU/Radiology/Blo
od Bank
 Primary Survey (ABC’S)
◦ Exclude early life threats (Tamponade, Tension
PTX,) and establish precese or risk of
HAEMORRHAGE SHOCK
◦ Manage Haemorrhage (immediate & plan definitive)
◦ Resuscitate patient (DCR)
◦ Usually all happen concurrently
 Secondary Survey (may not get to this)….
 Localise source/s
◦ Clinical / imaging

 • Initial control / minimise bleeding

◦ Pressure / Splinting / Traction / Tourniquet….
◦ DCR
 Plan for early definitive Mx of haemorrhage
 Multiple animal studies
◦ Reliable rebleeding point in pigs at SBP 94mmHg
◦ Hypotensive pigs aggressively resucitated (80ml/kg crystalloids)
 3 x blood loss & greatly increased mortality compared with nil resucitation
◦ Review of fluid resus in animals (Mapstone) – Permissive Hypotension vs
Normotension
 RR death 0.37 in permissive hypotension group
 Anecdotal / Retrospective
◦ WWI / WWII / Vietnam War
 Resuscitation in absence of bleeding control can be harmful
 • Human Studies
◦ Penetrating torso with BPPP<80 mmHg RCT (Houston): Delayed vs
Immediate resus
 Delayed: lower mortality (30% vs 38%), less crystalloids (375ml vs 2.5L, nil
diff in MAP)
◦ • Hypotensive trauma patients RCT : SBP target 70mmHg vs 100mmHg
 No change in mortality (ie. No increased mortality)
 Note no sig diff in SBP in the 2 groups
◦ Evidence suggests effect the same for Blunt & Penetrating
 Vasopressor Therapy
 Contraindicated for Hypovolemic Shock
 Sodium Bicarbonate
 Acidosis is a sign of poor perfusion and should be
treated with blood