SAQ 1 Monash Health Practise Exam 2014.2

1. SAQ 1Monash Health Practise Exam 2014.2

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%)

3. Management • Those aspects of care of the patient encompassing • treatment • supportive care • disposition

4. Management Treatment Supportive care Disposition

5. Management Manage ABC / Resuscitation Specific treatment Supportive care / monitor progress Manage complications Communication Consultation Disposition

6. 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

7.  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%)

8. 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

9.  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

10.  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)

11. 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?

12. 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

13. 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

14. 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?

15. 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

16. Communication & Consultation • Family/NOK • Inpatient specialties • If Listed in trauma call don’t need to repeat • Documentation

17. Disposition • OT then ICU • Is this enough detail?

18. 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

19. 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