Major trauma
Patient (condition)
 
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If assessing the patient in a regional center, make the decision regarding need for transfer by the end of primary survey to ensure that transfer is not delayed.

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Sep 13, 2012
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Use three people to log roll a small child :
1. One with both hands on the hips
2. One with both hands on the torso
3. One holding the head

#APLS

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Jan 08, 2013
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Indications for immediate surgery.

Head trauma: extra dural; sub dural.

Neck trauma: airway compromise, bleeding.

Thoracic trauma: tamponade; bleeding; tracheobronchial injury; haemodynamic collapse with possible penetrating cardiac injury; pulmonary venous air embolism.

Abdominal trauma: persistent haemodynamic instability with evidence of abdominal trauma

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Add C-spine immobilisation to your "A" in ABC assessment of the trauma patient
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Oct 13, 2012
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Paediatric spine boards have a cutout below the head to allow for neutral positioning of the neck, avoiding flexion which may exacerbate cervical spine injuries.
For longer duration immobilisation an occipan mat may be available.

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Decision of whether or not to intubate patients prior to CT scanning is based on a risk benefit analysis examining stability of the patient's vital signs, degree of patient co-operation, distance to transfer and remoteness of the CT scanner, and the availability of clinicians skilled with airway management to escort the unintubated patient. Whether the patient is intubated in the emergency department or operating theater then depends on the likelihood that urgent surgical intervention will be required following tracheal intubation (eg conversion of simple to tension pneumothorax) Yao and Artusio p998

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Oct 17, 2011
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If agitated patient with haemo/pneumothorax, pre-induction ICC may be dangerous to both patient & proceduralist. Consider intubating then inserting ICC

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Jun 13, 2011
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In difficult trauma airway scenarios, the chosen intubation technique should be one that the anesthesiologist is familiar with. This may be more relevant than the specific technology used.

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Oct 17, 2011
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The theoretical benefits of cricoid pressure during rapid sequence induction need to be weighed against the risk of directly exacerbating injury, or indirectly by causing the patient to cough.

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Oct 17, 2011
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Haemostatic resuscitation principles. Pre-emptively treat coagulopathy, maintain normal INR, 1:1:1 Blood:Platelets:Plasma. refl.in/81

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Jun 13, 2011
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If uncrossmatched O RH negative is not available, give uncrossmatched O Rh positive blood. #ref refl.in/81

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Oct 17, 2011
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In the unstable bleeding patient the management principle is one of permissive hypotensive resuscitation until hemostasis is achieved. In patients with no head injury, aim for conciousness and a systolic blood pressure over 90mmHg. In patients with uncontrolled haemorrhage plus a head injury, there exists a conflicting goal of maintaining cerebral perfusion pressure and minimising excessive blood pressure which increases blood loss. In this case, aim for conciousness and systolic over 110mmHg. #ref

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Oct 17, 2011
Good selection of papers dealing with the issue of permissive hypotension in uncontrolled hemorrhage. refl.in/ji
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May be intravascularly deplete with high SVR & at risk of exaggerated hypotension with general anaesthesia.

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May 18, 2011
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Patients who have had a longer duration of pre-hospital shock are likely to require greater blood product support to normalise coagulation

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Oct 17, 2011
#ref
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Urine output is not a reliable indicator of end organ perfusion in recently intoxicated patients due to the masking effects of the alcohol diuresis.

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Oct 17, 2011
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"For all major trauma patients, we recommend routine thromboprophylaxis, if possible. For major trauma patients, in the absence of a major contraindication, we recommend use of LMWH thromboprophylaxis starting as soon as it is considered safe to do so. An acceptable alternative is the combination of LMWH and mechanical thromboprophylaxis. For major trauma patients, if LMWH thromboprophylaxis is contraindicated due to active bleeding or high risk for clinically important bleeding, we recommend mechanical thromboprophylaxis with IPC, or possibly with GCS alone." refl.in/u

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Sep 26, 2011
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Oral antacids prior to rapid sequence induction are contraindicated in trauma patients at risk of oesophageal injury. Administration of intravenous H2 antagonists or promotility agents such as metoclopramide may be of some benefit in reducing gastric volume or acidity if administered 1-2hrs prior to intubation.

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Oct 17, 2011
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Tranexamic acid: CRASH2 trial showed early use improved mortality in bleeding trauma patients. Greatest effect when given within 1hr, but still effective if given within 3hrs. refl.in/lb and followup analysis refl.in

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Oct 16, 2011
1g intravenous loading dose in adults followed by 1g over 8hrs. refl.in/lb and followup analysis refl.in
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Study currently underway looking at cryoprecipitate in prehospital setting #ref

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Jun 13, 2011
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To remind yourself to stabilise the patient's cervical-spine, approach the patient with the "camp tyranosaurus" walk with both hands held forward like you're about to hold their head.
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