C
ABC (airway, breathing, circulation) is the primary survey.D
Airway management should be accompanied by cervical spine control.E
Oxygen should be administered with great care in polytraumatised patients who might suffer from chronic bronchitis.F
The physical signs of a tension pneumothorax are difficult to pick up in the resuscitation room and so it is best diagnosed by an immediate chest X-ray. 3. A 25-year-old motorcyclist comes inon a spine board with cervical spine control. He was found at the roadside unconscious following a collision with an oncoming car. The airway is clear but his breathing is clearly laboured with a respiratory rate of 40/min. His pulse is 110/min and his blood pressure is 90/60. It appears that the wing mirror of the car has penetrated his chest and there is a wound on the right side which is bubbling. He is not responding to verbal command but is muttering incoherently. He will not open his eyes.
(a) List the following tasks in their order of priority:
A
Insert a chest drain.B
Give 100 per cent oxygen.C
Put a flap valve dressing over the bubbling wound.D
Insert two wide-bore cannulae.E
Take an arterial blood gas (ABG) sample.F
Start checking for other injuries.G
Give intravenous (IV) fluids.H
Start a blood transfusion.CH022.indd 156
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During the secondary survey, you discover blood in one ear. The abdomen is silent and distending. The pelvis feels stable, but there is a wound over the left tibia which is obviously angulated. After the first bolus of fluid, the blood pressure rises to 100/70 mmHg (from 90/0) and the pulse falls to 105/min (from 110). A second bolus produces a further improvement, as does a third. The blood pressure is maintained. The chest drain is swinging normally and has drained 100 mL of blood. The patient’s conscious state has improved to the extent that he will open his eyes to command. The left foot is dusky-coloured. No pulses can be felt in the foot and there is no capillary refill. (b) List in order the priorities of your next
actions:
A
Take the patient to theatre immediately for a laparotomy.B
Get X-rays of the cervical spine, chest and pelvis.C
Get a CT of the chest and abdomen and head.D
Take the patient to theatre for debridement of the tibial wound.E
Ask for an arteriogram of the left leg.F
Put in a urinary catheter.4. A child of 3 years is brought into the A&E department having fallen from a first floor balcony. He is unconscious and breathing rapidly (60/min) but blood pressure and pulse are within normal limits. Primary survey reveals a bruise on the forehead and that pupils are equal and responding to
light. Air entry is good into both lungs. The abdomen appears distended and is silent. The pelvis is stable. The legs appear normal. It is not possible to gain IV access.
Put the following actions into order of priority:
A
The child should be moved to the ward and put on hourly neurological observation.B
Intraosseous needles should be inserted.C
Blood gases should be taken.D
Blood should be sent for cross-match.E
An ultrasound scan or CT scan of the abdomen should be obtained.F
The child should be taken straight to the operating theatre for a laparotomy. 5. A 70-year-old female falls and sustainsa fractured neck of femur. She is admitted to hospital at 7.30pm. She is a known hypertensive who is on diuretics and lives alone. You find her blood pressure is 160/100 mmHg and her pulse is 70/min. She is fully alert and orientated and has no other injuries.
Choose the best option:
A
Set her up for operation as soon as possible that evening.B
Wait until the blood results are back and then discuss the situation with the anaesthetist planning to optimise her for surgery on the morning list.C
Leave all planning until the morning as it is now ‘out of hours’.D
Insist that you operate that night, however long you have to wait.Answers: Multiple choice questions
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Epidemiology
1. B, F
Trauma is the commonest cause of death worldwide in the population aged 1–40. Within that group, road traffic accidents are the commonest cause of death with falls running second. Energy is important in predicting severity of injury. As the energy involved in an accident is proportional to the square of the velocity, an increase in speed of as little as 10 per cent leads to a 40 per cent increase in mortality.
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Seatbelts reduce the risk of injury by nearly 50 per cent and also prevent ejection, which is associated with a much higher mortality rate. Both seatbelts and airbags prevent large numbers of deaths and injuries. However, they also cause injuries (a far fewer number), characteristically in the abdomen and thorax.
The ATLS is a system for providing the safest and quickest possible diagnosis and treatment for any patient who has sustained polytrauma. The primary survey is carried out at the same time as the initial resuscitation. The secondary survey is aimed at checking all other parts of the body and systems once the primary survey has identified immediate life-threatening problems.