List the clinical effects of severe accidental hypothermia.
Definition: "severe" (usually mild 32-35, moderate 28-32, and severe < 28C). Accidental implies spontaneous decrease in core temperature, usually in a cold environment (more common in elderly, neonates, unconscious, exhausted, hypothyroid etc).
Mortality is signficant. Signs are modified by associated injuries, medications, extremes of age, etc.
Temperature control lost (become poikilothermic, cooling to ambient temperature)
Cardiac : arrhythmias (eg. bradycardia. AF and VF) decreased mean blood pressure, contractility, cardiac output
Respiratory: decreased respiratory rate, respiratory acidosis
CNS: variable effects on mentation and motor function; impaired judgement, disorientation, hyporeflexia
Haematology: coagulopatby, platelet dysfunction
Gastrointestinal: pancreatitis
Renal: polyuria, dehydration, ARF
The college specifies accidental hypothermia, which means the candidate could have included in their answer the entire spectrum of horrible environment-associated problems. One does not quietly cool on a clean surface. One typically is halfway immersed in an icy lake, trapped under a dead moose, or subject to another similarly complex retrieval situation. However, the college answer bypasses the accidental nature of the hypothermia, and speaks mainly of the non-specific consequences of low body temperature.
This topic is explored in greater depth in another chapter. The table of contents from this hypothermia chapter is a good summary of the physiological consequences of hypothermia
The above-referenced chapter on hypothermia has extensive references.
In order to simplify revision, I have identified four articles which cover this topic with a wealth of detail.
Wong, K. C. "Physiology and pharmacology of hypothermia." Western Journal of Medicine 138.2 (1983): 227.
Polderman, Kees H. "Application of therapeutic hypothermia in the intensive care unit." Intensive care medicine 30.5 (2004): 757-769.
Polderman, Kees H. "Mechanisms of action, physiological effects, and complications of hypothermia." Critical care medicine 37.7 (2009): S186-S202.
Mallet, M. L. "Pathophysiology of accidental hypothermia." Qjm 95.12 (2002): 775-785.
Discuss the mechanism, clinical symptoms and management of upper respiratory tract injuries due to burns.
Upper respiratory tract bums can be life threatening unless appropriately recognised and treated. Severity of inhalational injury has been related to various factors: beat of inhaled gases, composition of gases (presence of particles, steam and toxic products), duration of exposure, and pre·injury state.
Most of the upper .respiratory tract injury is due to the thermal insult (augmented by duration of exposure).
Initial symptoms may relate to associated injuries (facial burns), early oedema (intra-oral, pharyngeal, supraglottic/glottic/subglottic) with respiratory distress secondary to airway obstruction and increased work of breathing (tachypnoea, indrawing of soft tissues, tracheal tug), and patient · may be coughing or spitting carbonaceous material (signs are those of upper airway burn).
Management includes that of associated systemic effects such as bums to body (hypovolaemic shock etc), and inhalation of toxins (carbon monoxide, cyanide etc.). Management of the airway includes appropriate positioning of patient (eg. sitting up), close monitoring, and early definitive management of airway patency. Oedema worsens over the first few hours (persists for days) and may rapidly cause airway obstruction in untreated patients. Elective intubation should be considered early. A safe technique which took into account the potential for full stomach and difficult intubation was expected to be detailed.
Smoke inhalation is dealt with more broadly in Question 13 from the second paper of 2006. The lower respiratory complications of smoke inhalation are treated in greater detail in the answr toQuestion 26 from the first paper of 2012.
Apart from organising them by mechanism, symptoms and management, upper respiratory tract complications of smoke inhalation can be categorised by pathophysiology or anatomically, to make for a systematic answer.
Presented in this fashion, it could even be turned into a table.
Everyone likes tables.
Mechanism |
Specific factors |
Clinical features | Management |
Thermal |
|
|
|
Inflammatory |
|
|
|
Inhaled agents |
|
|
Or, one can organise them by anatomical location:
Anatomical location |
Mechanism |
Clinical features | Management |
Face |
|
|
|
Oral cavity |
|
|
|
Pharynx |
|
|
|
Larynx |
|
|
|
Trachea |
|
|
A good summary of airway burns can be found in the 2012 article
Lund, Tjostolv, et al. "Upper airway sequelae in burn patients requiring endotracheal intubation or tracheostomy." Annals of surgery 201.3 (1985): 374.
Bartlett, Robert H., et al. "Acute management of the upper airway in facial burns and smoke inhalation." Archives of Surgery 111.7 (1976): 744-749.
Gaissert, Henning A., Robert H. Lofgren, and Hermes C. Grillo. "Upper airway compromise after inhalation injury. Complex strictures of the larynx and trachea and their management." Annals of surgery 218.5 (1993): 672.
Bishop, Sophie, and Simon Maguire. "Anaesthesia and intensive care for major burns." Continuing Education in Anaesthesia, Critical Care & Pain 12.3 (2012): 118-122.
Describe the effects of the Intra-abdominal Compartment Syndrome. Outline your method for measuring intra-abdominal pressure and explain the pitfalls of this method.
Discussion on the effects of the ICS should include:
• renal effects – capillary compression, decreased GFR/UO, ATN,
• bowel – decreased SMA/coeliac flow, decreased pHi, bowel ischaemia
• hepatic – decreased portal blood flow, lactate clearance
• cardiac –decreased venous return/cardiac output, elevated PAOP/CVP/afterload
• respiratory –increased PIP, shunt, Paw,
• cerebral – increased ICP, decreased CPP
Description of a simple, sterile and practical technique for measurement of intra-vesical pressure was expected.
Pitfalls include:
• using the wrong zero point
• allowing a leak in the system to produce a falsely low reading
• chronic cystitis, radiation cystitis producing a small contracted bladder with low compliance which gives a falsely high reading
• pelvic haematoma producing a tight pelvic compartment with falsely elevated IAP.
The majority of this question is answered by the discussion of Question 8 from the first paper of 2013. A slightly less formal discussion of abdominal compartment syndrome takes place in Question 21 from the second paper of 2006: "Outline the causes, consequences and the management of abdominal compartment syndrome. "
The "pitfalls" section is not addressed anywhere else.
Briefly, the following are reasons as to why one's intrabdominal measurements may be wrong:
You are called to see a 65 year old male tourist who has been admitted to your emergency department after being hit by a car while attempting to cross a busy street. He is unconscious and has obvious chest and limb injuries.
(a) Please outline your initial management of this patient.
Organized approach is essential. ATLS/EMST approach should be used. Most emergency departments that receive trauma do so with facilities that support a trauma team concept. Initial management should be undertaken as part of the trauma team, with roles usually well delineated.
Initial management requires simultaneous primary survey, resuscitation and assessment of history, followed by a secondary survey then definitive care.
Primary survey involves assessment of adequacy of airway, breathing and circulation (with interventions at each point whenever identified), followed by assessment of neurological state (pupils, level of consciousness, localising signs) and adequate exposure to assess major injuries. Indications for endotracheal intubation should be clearly described (GCS < 9, hypoxia/respiratory distress etc.). Initial ventilatory management should be detailed (respiratory rate, tidal volume, blood gas goals etc). Fluid administration and goals of resuscitation should be discussed. Relevant history should be obtained from ambulance officers, family, witnesses etc. In particular details about the mechanism of injury and patient’s previous medical condition, medications and allergies etc.
Secondary survey involves a detailed head to toe examination to assess extent of injuries (including flanks, back and rectal examination), as well as a detailed neurological assessment.
Definitive care involves planning for surgery, other specialist involvement and transfer as appropriate.
A systematic approach to this answer would follow the normal ATLS pattern of the primary survey.
A) - Urgent assessment of the airway, and of the need for immediate intubation (with in-line spinal stabilisation). A very high spinal cord injury may have resulted in respiratory arrest.
The decreased level of consciousness suggests that intubation is required.
B) - Evaluation of respiratory function and chest injuries. This patient can potentially have a tension or non-tension pneumothorax or haemothorax, and this diagnosis needs to be made early in the primary survey. High FiO2 should be administered. One should look for paradoxical respiration pattern due to flail chest, or diaphragmatic breathing due to high spinal cord injury.
C)
Features of hypovolemia (eg. cool peripheries, pallor) should be sought. Blood should be sampled for crossmatch, and uncrossmatched blood should be transfused if the patient is demonstrating features of anaemia. Large-bore IV access should be established.
Blood products should be preferentially used for resuscitation, with a 1:1:1 ratio of PRBCs, FFP and platelets. The MAP target for fluid resuscitation should be a MAP >50mmHg.
D) The level of consciousness should be assessed. Features of spinal cord injury should be pursued on examination. Pupils should be examined to assess for signs of herneation.
E) The patient needs to be rewarmed (presuming they are hypothermic) and a blood warmer should be connected to maintain normothermia in spite of massive resuscitation
After the completion of the primary survery, the following investigations must urgently take place:
This pathway of investigation should be abandoned and urgent damage control surgery should take place if any of the above assessment methods make it abundantly clear that a catastrophic shock state due to abdominal or thoracic haemorrhage is developing.
Definitive transfer arrangements must be made if definitive care cannot be offered at the current facility.
ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma
You are called to see a 65 year old male tourist who has been admitted to your emergency department after being hit by a car while attempting to cross a busy street. He is unconscious and has obvious chest and limb injuries.
(b) Please discuss the timing and nature of any investigations which you would perform.
Urgent early investigations include urea and electrolytes, full blood examination and blood group and cross match (done when initial venous access is obtained). It is reasonable to also perform arterial blood gas analysis and a coagulation profile at this time.
During the resuscitation phase before the secondary survey, it is reasonable to get a lateral cervical spine, supine chest X-ray, and pelvis X-ray, as long as this can be done without moving the patient to a separate area. Some specific abdominal assessment should be made as the patient is unconscious (DPL, FAST or CT scan), earlier if haemodynamically unstable. A urinary catheter (unless contraindicated) should be inserted at this time to monitor urine output, and an ECG should be obtained (± echocardiography or CVP monitoring if unsure of cardiovascular status).
More specific X-rays of suspected or high risk areas (eg. full cervical spine series, chest CT and head CT, limb and thoracic and lumbar spine X-rays) should be done when patient is haemodynamically stable and ideally before transfer to ICU or theatre (unless required urgently). Definitive exclusion of thoracic aortic injury (trans-oesophageal echocardiography or CT angiography) should be performed if clinically indicated when haemodynamically stable.
Repeat assessment of blood gases, Hb and coagulation may be needed early.
Intra-cranial pressure monitoring may be required depending on clinical status or CT appearance (in this 65 year old man). This is not usually urgent, but may facilitate titration of modalities to control ICP and CPP. It may be inserted in ICU or pre-operatively if prolonged time in the operating theatre is anticipated.
This is a question about the initial blood workup and primary/secondary survey investigations.
Thus:
Bloods:
Imaging
Monitoring
ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma
You are called to see a 65 year old male tourist who has been admitted to your emergency department after being hit by a car while attempting to cross a busy street. He is unconscious and has obvious chest and limb injuries.
Please discuss your plan for his definitive care (including fixation of long bone fractures etc.).
This patient has major trauma with head, limb and chest injuries, and should be managed in a centre that is experienced in trauma care. If this hospital is not able to provide sufficient services then early communication with a receiving hospital is essential, and plans made for expedient transfer.
Specific neurosurgery may be necessary if intracranial haemorrhage is detected and should be performed within the first few hours. Thoracic surgery is rarely required (eg. dependent on amount of bleeding from intercostal tubes), but surgery will be required for long bone fractures. Compound fractures should be dealt with early (hours), as should injuries with vascular compromise. Other operations are less urgent and the role of early fixation of fractures is controversial. In the absence of significant respiratory compromise it is probably reasonable to progress to early fixation. If instead there is concern about respiratory status then external fixation rather than internal fixation may be preferable on the first day, followed by more specific management a few days later.
This question would benefit from a systematic response.
Thus:
ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma
Outline your approach to the pain management of a pedestrian (hit by a car) who has significant chest injuries.
It may be very difficult to obtain adequate analgesia in patients with significant chest injuries. The various options available may be limited by associated injuries, in particular the presence of a closed head injury, an uncleared cervical or thoraco-lumbar spine, a coagulopathy or renal injury. The options available may also be limited by the area in which the patient will be managed, though these patients should be managed in at least a high dependency unit. Patient sensitivities or allergies, and past illnesses (eg. bleeding ulcer) may also restrict choices.
The options available which should be discussed are multiple and include combinations of:
• simple parenteral opioids (infusion, boluses, PCA), with the use of adjuvant agents
(tramadol, NSAIDs, paracetamol, codeine)
• regional techniques (including epidural analgesia with local anaesthetics and/or opioids, interpleural local anaesthetics or intercostal blocks).
Pain management in chest injuries is touched upon in the answer to Question 26 from the first paper of 2010, "Outline the relative advantages and disadvantages of thoracic epidural analgesia compared to systemic opioid analgesia via a PCA (Patient Controlled Analgesia)"
To simplify revision, that comparison table is reproduced below.
Additionally, an excellent resource on acute pain management in chest injury is available from theJournal of Trauma, Injury, Infection and Critical Care.
Thoracic epidural |
Systemic opiates via PCA |
|
Advantages |
|
Staff very familiar with use |
Disadvantages |
|
• Increasing age associated with increasing adverse effects from opiates, especially bowel dysfunction, nausea, drowiness |
Additional issues can be brought up.
Regional analgesic techniques are gaining in popularity:
Opiate-sparing analgesic agents can be used:
Agents to manage a neuropathic component of the pain can be used:
Non-pharmacological methods may be employed:
Karmakar, Manoj K., and Anthony M-H. Ho. "Acute pain management of patients with multiple fractured ribs." Journal of Trauma-Injury, Infection, and Critical Care 54.3 (2003): 615-625.
A 24-year-old male mountain bike rider crashes into a tree, resulting in a severe hyperextension neck injury, and fractured lower left ribs. He now presents to hospital with shock and a painful distending abdomen.
a) Describe your initial management.
a) Describe your initial management.
Initial management of trauma should be according to standard protocol. Initial primary survey and resuscitation would address adequacy of airway (patency, need for ETT) and breathing (eg. excluding tension pneumothorax and major haemothorax). At the review of “circulation” phase, the presence of shock with obvious abdominal signs means urgent surgery is required (with simultaneous insertion of 2 wide bore IVs if not already present, removal of blood for Hb/platelets, crossmatch and clotting profile, rapid infusion of 2 litres of fluid [blood if significant previous non- blood resuscitation]. In the time until surgery is organised, it may be possible to perform a supine CXR, pelvic X-ray and/or a FAST (ultrasound) examination. He must be treated with spinal precautions (including for intubation) as it must be assumed that there is an unstable cervical spine, with possible thoraco-lumbar spine injuries. Attempts should be made to maintain his temperature stable (eg. >35-36°C). Full secondary survey and specific investigations must be deferred until the haemodynamic state is adequately dealt with.
This question is identical to Question 12 from the second paper of 2005.
A 24-year-old male mountain bike rider crashes into a tree, resulting in a severe hyperextension neck injury, and fractured lower left ribs. He now presents to hospital with shock and a painful distending abdomen.
b) He returns from the operating theatre after a splenectomy. He is haemodynamically stable, but little is known of his other injuries. What is your plan for the next 24 hours?
At this stage stability must be confirmed in other areas as well as haemodynamic. Blood pressure goals should consider spinal perfusion pressure if spinal injury is suspected, and steroids should be considered in the first 8 hours.
Now is the time to ensure that oxygenation and ventilation are stable; coagulation should be assessed and corrected if abnormal; and temperature should be in target range. Secondary survey should be completed, including detailed neurologic examination (eg. in an attempt to exclude spinal injury). Spinal precautions should be continued for the interim. The primary x-rays should be obtained (CXR, pelvic x-ray, lateral cervical spine) but now additional x-rays should be obtained as indicated (repeat CXR, spinal series ± CTs eg. of cervical spine, chest, abdomen). Long bone injuries should be sought and excluded (or treated). Other specialists should be asked to review patient as indicated (eg. cardiothoracic, spinal). Antibiotics and tetanus prophylaxis should be prescribed if indicated. Anti-ulcer prophylaxis should be instituted, and as should pharmacological prophylaxis for DVTs when contraindications subside. Enteral feeding should be started as soon as practical.
This question about post-splenectomy ICU management is identical to Question 13 from the second paper of 2005.
You are called to see a 39 year old female driver in the Emergency Department who has been brought in by ambulance after a motor vehicle crash (head on collision). She is eight months pregnant (first pregnancy), and is complaining of abdominal pain.
(a) Please outline your initial management of this patient.
The additional complicating factor of pregnancy expands the differential diagnosis, and requires additional investigation and monitoring, and complicates the performance of many interventions. Standard ACLS/EMST management of the initial presentation should be performed.
Primary survey: [airway {and cervical spine}, breathing, circulation, disability and exposure] with high flow oxygen and standard monitoring. Standard resuscitation and initial Xrays should be performed with a lead apron covering the abdomen whenever possible.
Secondary survey: Abdominal examination is even less reliable than usual, and concern about foetal well-being and the possibility of abruption should be considered. Uterine rupture is rare without previous uterine surgery. Early consultation should occur with an obstetrician, and Cardio-Toco-Graphic monitoring should be implemented. Focused Abdominal Sonography in Trauma is still reliable, and abdominal CT scan is not contraindicated, and may help in the diagnosis of abruption.
This question forms a part of the "manage this pregnant trauma patient" spectrum of fellowship questions. For a general reference, one is directed to Question 3 from the first paper of 2007 (Outline the special considerations involved in the care of a pregnant patient involved in multi-trauma.). Question 6 from the first paper of 2000 also touches on the ways in which physiological changes in pregancy affect the scenario of trauma. Specific features of the cardiorespiratory changes in pregnancy can also be found on the page dedicated to this topic
In brief, one should recall the following issues:
Oh's Intensive Care manual: Chapter 64 (pp. 684) General obstetric emergencies by Winnie TP Wan and Tony Gin
Soar, Jasmeet, et al. "European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution." Resuscitation 81.10 (2010): 1400-1433.
Mattox, Kenneth L., and Laura Goetzl. "Trauma in pregnancy." Critical care medicine 33.10 (2005): S385-S389.
DROST, THOMAS F., et al. "Major trauma in pregnant women: maternal/fetal outcome." Journal of Trauma-Injury, Infection, and Critical Care 30.5 (1990): 574-578.
You are called to see a 39 year old female driver in the Emergency Department who has been brought in by ambulance after a motor vehicle crash (head on collision). She is eight months pregnant (first pregnancy), and is complaining of abdominal pain.
(b) Please discuss the timing and nature of any investigations that you would perform.
Consider: Immediate: blood for group (consider Rhesus isoimmunisation), cross match, electrolytes, full blood examination and coagulation profile. Xrays of chest and cervical spine (&/or pelvis), delaying other Xrays until stable.
Early: abdominal ultrasound (FAST, uterus and foetal heart rate), CTG
Once stable: abdominal CT, thoracic and lumbar spine films (if can’t clear clinically in view of distractors). DPL probably not of additional help, unless other investigations unavailable.
This question is about immediate bloods, and the investigations which form part of the secondary survey. How are these different in a pregnant patient? A generic approach to the pregnant trauma patient is discussed in Question 3 from the first paper of 2007.
The usual barrage of blood tests remains unchanged.
FBC, EUC, CMP LFT coags and crossmatch get sent away just as they would in any trauma patient, but the savvy candidate will mention the need for Rh blood grouping to prevent Rh isoimmunisation (where the mother is Rh negative and the foetus is Rh positive). An administration of anti-Rh IVIG can mop up any Rh-positive foetal erythrocytes which might have haemorrhaged into the maternal circulation, preventing the mother from developing her own anti-Rh antibodies (and thus preventing the haemolytic disease of the newborn).
An abdominal ultrasound (FAST) is still performed, with additional focus on the uterus; uterine rupture or placental abruption need to be detected early.
Foetal welfare can be monitored by CTG, and the O&G specialist should be invited to perfrom their own focused ultrasound to investigate the pregnancy.
Though radiation exposure is undesirable, it is tolerated (particularly in late term pregnancy) because organogenesis has already taken place, and because the risk from ionising radiation exposure is minute in comparison to the risk of missed injuries and haemorrhage.
Kuczkowski, K. M. "Trauma during pregnancy: a situation pregnant with danger." Acta Anaesthesiol Belg 56.1 (2005): 13-18.
Oxford, Corrina M., and Jonathan Ludmir. "Trauma in pregnancy." Clinical obstetrics and gynecology 52.4 (2009): 611-629.
Goodwin, Hillary, James F. Holmes, and David H. Wisner. "Abdominal ultrasound examination in pregnant blunt trauma patients." Journal of Trauma-Injury, Infection, and Critical Care 50.4 (2001): 689-694.
Compare and contrast the roles of angiography and surgical management in the management of the critically ill patient with ongoing haemorrhage due to pelvic fractures.
Practice management guidelines exist for the management of haemorrhage in pelvic fracture. The general principles are included below.
Angiography is not always required but may be life saving. It requires specialist radiology expertise (not necessarily widely available), requires transport to and needs to be performed in an area that may not be adequately set up for the complex monitoring and resuscitation that may be required in an unstable patient. Definitive selective embolisation may be able to be achieved to control arterial bleeding where other strategies (e.g. pelvic stabilisation or laparotomy) have failed.
Some form of surgical management is probably required in all cases, as at least some form of immobilisation (usually external fixation) will be required for unstable pelvic fractures. Laparotomy is indicated for the associated traditional signs of intra-abdominal bleeding or intestinal perforation. Apart from definitive stabilisation, other definitive surgical management is not usually helpful apart from general packing (without exploration) for venous haemorrhage, and rarely ligation of internal iliac arteries for uncontrollable arterial haemorrhage. Some aspects of surgical management may be able to be performed outside the operating room; otherwise transport is required (but to an area set up for ongoing monitoring and stabilisation).
Since 2004, technology has moved on, and so the opinion has shifted in favour of early angioembolisation. Even in 2003 this study supported the use of earlier angio for anybody with evidence of arterial bleeding. Furthermore, there is good evidence for a angiographic "mop-up" of bleeding which has not resolved after external surgical fixation.
This question would benefit from a 2 × 2 table of advantages and disadvantages.
Surgery | Angio-embolisation | |
Advantages |
|
|
Disadvantages |
|
|
Miller, Preston R., et al. "External fixation or arteriogram in bleeding pelvic fracture: initial therapy guided by markers of arterial hemorrhage." Journal of Trauma-Injury, Infection, and Critical Care 54.3 (2003): 437-443.
Flint Jr, LEWIS M., et al. "Definitive control of bleeding from severe pelvic fractures." Annals of surgery 189.6 (1979): 709.
Cullinane, Daniel C., et al. "Eastern Association for the Surgery of Trauma practice management guidelines for hemorrhage in pelvic fracture—update and systematic review." Journal of Trauma and Acute Care Surgery 71.6 (2011): 1850-1868.
Metsemakers, W-J., et al. "Transcatheter embolotherapy after external surgical stabilization is a valuable treatment algorithm for patients with persistent haemorrhage from unstable pelvic fractures: outcomes of a single centre experience." Injury 44.7 (2013): 964-968.
Rossaint, Rolf, et al. "Management of bleeding following major trauma: an updated European guideline." Crit care 14.2 (2010): R52.
A 24-year-old male mountain bike rider crashes into a tree, resulting in a severe hyperextension neck injury, and fractured lower left ribs. He now presents to hospital with shock and a painful distending abdomen.
He returns from the operating theatre after a splenectomy. He is haemodynamically stable, but little is known of his other injuries. What is your plan for the next 24 hours?
At this stage stability must be confirmed in other areas as well as haemo-dynamic. Blood pressure goals should consider spinal perfusion pressure if spinal injury is suspected (may be unable to achieve target “normal” MAP in presence of high spinal injury), steroids should be considered in the first 8 hours following injury (“NASCIS II”).
Now is the time to ensure that oxygenation and ventilation are stable; coagulation should be assessed and corrected if abnormal; and temperature should be in target range.
Secondary survey should be completed, including detailed neurologic examination (eg. in an attempt to exclude spinal injury). Spinal precautions should be continued for the interim. The primary X rays should be obtained (CXR, pelvic X-ray, lateral cervical spine) but now additional
X-rays should be obtained as indicated (repeat CXR, spinal series ± CTs eg. of head, cervical spine, chest, abdomen). Long bone injuries should be sought and excluded (or treated).
Other specialists should be asked to review patient as indicated (eg. cardiothoracic, spinal). Antibiotics and tetanus prophylaxis should be prescribed if indicated.
Anti-ulcer prophylaxis should be instituted, and as should pharmacological prophylaxis for DVTs when contraindications subside. Enteral feeding should be started as soon as practical, and glycaemic control should be implemented.
This question is about the management of a trauma patient who returns from theare following damage control surgery. It seems some definitive management (splenectomy) has already taken place.
The college mention the use of corticosteroids in spinal cord injury; this is not something we do any more. In fact, there is no strong evidence behind any of the pharmacologial measures. However, the idea of "spinal perfusion pressure" is interesting. The current guidelines are not so bold as to suggest a MAP of 85, but they do recommend the systolic not be allowed to drop below 90, which is slightly contrary to the doctrine of permissive hypotension in damage control resuscitation.
Anyway, the college baits us with the words "little is known of his other injuries".
A secondary survey must take place, including the following:
A systematic, boring response to the question of supportive management would resemble the following:
A) - Airway control and adequate secretion clearance with suctioning, given the increased risk of pneumonia
B) - Adequate ventilation and oxygenation, with sufficient PEEP to splint the rib fractures and prevent left-sided atelectasis
C) - Haemodynamic control, with less conservative MAP targets - maintaining a MAP >65 mmHg, and SBP >90mmHg.
D) - Attention to spinal precautions, and deescalation of hard collar as soon as the spine is cleared. Adequate analgesia.
E) - Control of electrlytes, paying attention to the calcium
F) Adequate fluid resuscitation, aiming for a high normal urine output given the tendency of these patients to dveelop ATN due to haemoglobinuria and rhabdomyolysis
G) Reassessment of the abdomen to exclude ongoing bleeding.
Insertion of an NG tube if permitted by facial injuries, and commencement of enteral feeding, with the aim to supply a daily minimum of 2g protein per kg of body mass.
Ulcer prophylaxis with PPI may not be necessary of the enteral nutrition is well tolerated.
Glucose control should be established with insulin as needed.
H) Corection of anaemia and dilutional coagulopathy;
Attention to thromboprophylaxis, given that trauma (and especially spinal trauma) patients have the highest likelihood of developing DVTs.
I) No indication for antibiotics at this stage. An ADT should be given IM if it was omitted in ED.
Hurlbert, R. John. "Strategies of medical intervention in the management of acute spinal cord injury." Spine 31.11S (2006): S16-S21.
AANS Guidelines for the management of acute cervical spine and spinal cord injuries.
"Blood pressure management after acute spinal cord injury." Neurosurgery. 2002 Mar;50(3 Suppl):S58-62.
Outline the role of regional anaesthetic techniques in the management of pain in the critically ill.
Many candidates provided long lists of regional techniques, but did address the issues of when to use and when not to use a technique. Consider asking “why don’t we perform more epidurals in our patients?”.
Advantages of regional anaesthetic techniques include
• reduced narcotic use to achieve analgesia– less respiratory depression, especially in chest injury or high risk of respiratory failure (elderly, COPD, etc)
• less ileus (reduce risk of aspiration, tolerance of enteral feeds, etc)
• less interference with mental status (harder to attribute obtundation to drugs or injury)
• reduces use of non narcotics, eg NSAIDS (renal impairment, platelet function); tramadol (confusion in elderly); paracetamol – all just adjuncts anyway and less efficacious than regional in severe pain; ketamine – hypertension, tachycardia, dissociative effects, etc)
Disadvantages (general)
• often redundant in sedated, ventilated patient
• not proven in critically-ill to be any better in terms of outcome in critically ill patients – thus not a lot of strong evidence to support use in critically ill over above alternatives
• problems with local anaesthetic toxicity fairly uncommon with newer agents given by infusion (eg ropivacaine via epidural) – but some other regional blocks (eg brachial plexus catheters, pleural catheters, etc can get to higher dosages and greater risk of toxicity)
• may still need narcotic adjuncts
• technical expertise required
• difficulty covering multiple sources of pain
• sympathetic blockade, problems with coagulopathy, need for patient positioning, anatomical landmarks may be difficult
• catheters over longer term => risk of infection. Also confused patients more likely to dislodge them
• monitoring of blockade in uncooperative patient may be impossible
• removal with DVT prophylaxis may be an issue
Disadvantages (local)
• related to sites of placement – eg vascular injection, pneumothorax, other neuro injury, etc, etc. Also neuro blockade in presence of “uncleared” neurological injury and following plastic surgery for nerve injury.
It is difficult to lump epidural and other regional techniques together.
So, I un-lumped them, for largely cosmetic reasons.
Epidural |
Peripheral nerve block |
|
Advantages |
|
|
Disadvantages |
|
|
Wu, Christopher L., et al. "Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash." Journal of Trauma-Injury, Infection, and Critical Care 47.3 (1999): 564-567.
MACKERSIE, ROBERT C., et al. "Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures." Journal of Trauma-Injury, Infection, and Critical Care 31.4 (1991): 443-451.
Kieninger, Alicia N., et al. "Epidural versus intravenous pain control in elderly patients with rib fractures." The American journal of surgery 189.3 (2005): 327-330.
Moon, M. Ryan, et al. "Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma." Annals of surgery 229.5 (1999): 684.
Jarvis, Amy M., et al. "Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis." OPUS 12 (2009): 50-57.
Scherer, R., et al. "Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients." Acta anaesthesiologica scandinavica 37.4 (1993): 370-374.
Kapral, Stephan, et al. "The effects of thoracic epidural anesthesia on intraoperative visceral perfusion and metabolism." Anesthesia & Analgesia 88.2 (1999): 402-406.
A 24-year-old male mountain bike rider crashes into a tree, resulting in a severe hyperextension neck injury, and fractured lower left ribs. He now presents to hospital with shock and a painful distending abdomen.
Describe your initial management.
Initial management of trauma should be according to standard protocol.
Initial primary survey and resuscitation should address adequacy of airway (patency, need for ETT)
and breathing (eg. excluding tension pneumothorax and major haemo-thorax).
At the review of “circulation” phase, the presence of shock with obvious abdominal signs means urgent surgery is required, with simultaneous insertion of 2 wide bore IVs if not already present, removal of blood for Hb/platelets, cross-match and clotting profile, rapid infusion of 2 litres of fluid [blood if significant previous non-blood resuscitation].
In the time until surgery is organised, it may be possible to perform a supine CXR, pelvic X-ray and/or a FAST (ultrasound) examination/DPL/abdominal CT if able to be kept haemo-dynamically stable. Consideration of angiography if stability maintained and expertise available.
He must be treated with spinal precautions (including for intubation) as it must be assumed that there is an unstable cervical spine, with possible thoraco-lumbar spine injuries.
Attempts should be made to maintain his temperature stable (eg. > 35-36°C). Full secondary survey and specific investigations must be deferred until the haemo-dynamic state is adequately dealt with.
This patient has four major issues:
A systematic approach to this answer would follow the normal ATLS pattern of the primary survey.
A) - Urgent assessment of the airway, and of the need for immediate intubation (with in-line spinal stabilisation). A very high spinal cord injury may have resulted in respiratory arrest.
B) - Evaluation of respiratory function and chest injuries. This patient can potentially have a tension or non-tension pneumothorax or haemothorax on the left side, and this diagnosis needs to be made early in the primary survey. High FiO2 should be administered. One should look for paradoxical respiration pattern due to flail chest, or diaphragmatic breathing due to high spinal cord injury.
C)
The major differentials for this shock state include the following:
Features of hypovolemia (eg. cool peripheries, pallor) should be sought. In any case, volume replacement is indicated in each of the abovementioned differentials. Blood should be sampled for crossmatch, and uncrossmatched blood should be transfused if the patient is demonstrating features of anaemia. Large-bore IV access should be established.
Blood products should be preferentially used for resuscitation, with a 1:1:1 ratio of PRBCs, FFP and platelets. The MAP target for fluid resuscitation should be a MAP >50mmHg.
D) The level of consciousness should be assessed. Features of spinal cord injury should be pursued on examination
E) The patient needs to be rewarmed (presuming they are hypothermic) and a blood warmer should be connected to maintain normothermia in spite of massive resuscitation
After the completion of the primary survery, the following investigations must urgently take place:
This pathway of investigation should be abandoned and urgent damage control surgery should take place if any of the above assessment methods make it abundantly clear that a catastrophic intraabdominal source of bleeding is responsible for the shock state.
ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma
Outline the pathophysiology and clinical features of a smoke inhalation injury in a patient with major burns.
Key Features
a) CO/CN toxicity – Lactic acidosis, high SvO2, mental confusion, hypotension
b) Upper airway obstruction from airway oedema – soot in the pharynx, singed hair, stridor, hoarseness, oropharyngeal erythema, oedema and blistering
c) Chemical burns to the lungs which result in mucosal damage, bronchitis, mucous plugging and pulmonary oedema – Bronchospasm, bronchorrhoea, raised a-a gradient
Smoke inhalation injuries are discussed in greater detail in the answer to Question 26 from the first paper of 2012. One can divide this issue into mechanisms of thermal and inhalational injury, pathophysiological changes, damage at varying anatomical levels, and probably all of the above are reasonable approaches.
Presented in this fashion, it could even be turned into a table.
Everyone likes tables.
Mechanism |
Specific factors |
Clinical features | Management |
Thermal |
|
|
|
Inflammatory |
|
|
|
Inhaled agents |
|
|
Or, one can organise them by anatomical location:
Anatomical location |
Mechanism |
Clinical features | Management |
Face |
|
|
|
Oral cavity |
|
|
|
Pharynx |
|
|
|
Larynx |
|
|
|
Trachea |
|
|
A good summary of airway burns can be found in this 2012 article
Lund, Tjostolv, et al. "Upper airway sequelae in burn patients requiring endotracheal intubation or tracheostomy." Annals of surgery 201.3 (1985): 374.
Bartlett, Robert H., et al. "Acute management of the upper airway in facial burns and smoke inhalation." Archives of Surgery 111.7 (1976): 744-749.
Gaissert, Henning A., Robert H. Lofgren, and Hermes C. Grillo. "Upper airway compromise after inhalation injury. Complex strictures of the larynx and trachea and their management." Annals of surgery 218.5 (1993): 672.
Bishop, Sophie, and Simon Maguire. "Anaesthesia and intensive care for major burns." Continuing Education in Anaesthesia, Critical Care & Pain 12.3 (2012): 118-122.
Outline the causes, consequences and the management of abdominal compartment syndrome.
Causes:
Abdominal trauma
Massive retroperitoneal hematomas
Major burns following fluid resuscitation
Massive intra-abdominal hemorhage
Major Consequences:
a) Decrease in Qt because of a decrease in venous return
b) Decreased renal perfusion
c) Impaired thoracic compliance
d) Bowel ischemia
Management
a) Monitoring intra-abdominal pressure
b) Abdominal decompression
c) Adequate decompression of GI tract
d) Avoiding excess fluid resuscitation
A slightly more formal-looking exploration of abdominal compartment syndrome can be found in Question 8 from the first paper of 2013. Brief notes on the pathophysiology of abdominal compartment pressure and its measurement are available, with references for the time-rich exam candidate.
Causes of abdominal compartment syndrome:
Primary ACS: increased compartment pressure due to abdominal pathology
Secondary ACS: increased compartment pressure due to fluid resuscitation
Consequences of abdominal compartment syndrome:
Management of abdominal compartment syndrome:
Cheatham, Michael Lee. "Abdominal compartment syndrome." Current opinion in critical care 15.2 (2009): 154-162.
Maerz, Linda, and Lewis J. Kaplan. "Abdominal compartment syndrome."Critical care medicine 36.4 (2008): S212-S215.
Saggi, Bob H., et al. "Abdominal compartment syndrome." Journal of Trauma-Injury, Infection, and Critical Care 45.3 (1998): 597-609.
Cheatham, Michael L., et al. "Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension." Journal of Trauma-Injury, Infection, and Critical Care 49.4 (2000): 621-627.
List the symptoms, signs, causes and treatment of Fat Embolism Syndrome.
Symptoms ie dyspnoea, confusion,
Signs Respiratory, CNS, cutaneous,
Causes Long Bone #s, smaller bones, sickle cell, compression liposuction etc
Treatment: Supportive ie O2, CPAP, Ventilation.
For a ten mark question, the college answer - though technically hitting all the correct notes- appears a little austere.
A more generously expanded answer could be constructed using the various published review literature on the subject. It would resemble something like the following:
Symptoms of fat embolism
Signs of fat embolism
Laboratory features
Causes of fat embolism
Management of fat embolism
Weird management strategies have been advanced, such as heparin (which supposedly encourage lipase activity and discourages the formation of pletelt aggregates). Alcohol intoxication seems to be somehow protective against fat embolism.
Mellor, A., and N. Soni. "Fat embolism." Anaesthesia 56.2 (2001): 145-154.
Gurd, Alan R., and R. I. Wilson. "The fat embolism syndrome." Journal of Bone & Joint Surgery, British Volume 56.3 (1974): 408-416.
Myers, R., and J. J. Taljaard. "Blood alcohol and fat embolism syndrome." J Bone Joint Surg Am 59.7 (1977): 878-880.
Hofmann, S., G. Huemer, and M. Salzer. "Pathophysiology and management of the fat embolism syndrome." Anaesthesia 53.S2 (1998): 35-37.
Outline the special considerations involved in the care of a pregnant patient involved in multi-trauma.
a High flow 02 to avoid maternal and fetal distress
b. Reduced respiratory reserve
c. Matemal compensation for blood loss is at ilie expense of uteroplacental flow
d. Avoid aortocaval compression
e. Transfusion should be Rh compatible
f All Rh negative mothers to receive lg because of the immunological risk of minor fetomatemal hemorrhage
g. Minimal exposure to radiation
h. U/S may be preferable
i. Retroperitoneal hemorrhage, placental abruption, fetal distress may occur
j. Premature labour may be precipitated
k. Need for regular cardiotocograph.
I. ·Pelvic binders may be unsuitable
m. Physiological anemia of pregnancy
The management of the pregnant poly-trauma patient is discussed elsewhere.
This is one of those questions which could fit equally well into the "pregnancy and obstetrics" category.
In summary:
Issues to consider in investigations and the secondary survey
Oh's Intensive Care manual: Chapter 64 (pp. 684) General obstetric emergencies by Winnie TP Wan and Tony Gin
Soar, Jasmeet, et al. "European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution." Resuscitation 81.10 (2010): 1400-1433.
Mattox, Kenneth L., and Laura Goetzl. "Trauma in pregnancy." Critical care medicine 33.10 (2005): S385-S389.
DROST, THOMAS F., et al. "Major trauma in pregnant women: maternal/fetal outcome." Journal of Trauma-Injury, Infection, and Critical Care 30.5 (1990): 574-578.
Outline your management of thoracic epidural analgesia in a 56 year old man who has stable angina on a beta blocker who has been involved in a motor vehicle accident causing a left-sided flail chest. What are the most potential complications?
Important considerations include:
a) Other injuries need to be ruled accounted for that may have implications – spinal injury, intra-abdo injury (though abdo pain from intra-abdo injury not likely to be totally masked by epidural local anaesthetic)
b) Coagulopathy is a contraindication
c) Epidural Local anaesthetic/opiate combination at thoracic level likely to be associated with hypotension/bradycardia needing volume and likely inotropic support –relatively contraindicated in a middle aged male on beta blockers.
Infusion vs bolus vs PCEA
d) Other epidural analgesics – opiate alone eg fentanyl, pethidine or epidural clonidine –
doses/frequency
Complications:
a) Hypotension, bradycardia
b) Masking of abdominal / evolving neurological signs
c) Inadequate analgesia due to limited / patchy block
d) Increased pain in unblocked areas – relative phenomenon esp with bony injury eg shoulder.
e) Short duration of blockade – catheters usually removed after 3 days.
f) Epidural haematoma / abscess
g) Epidural drug side effects – pruritus, nausea, respiratory depression
h) Hypotension on mobilisation
Thoracic epidural anaesthesia is compared to a parenteral opiate PCA in Question 26 from the first paper of 2010.
Management considerations:
Complications of thoracic epidural
Wu, Christopher L., et al. "Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash." Journal of Trauma-Injury, Infection, and Critical Care 47.3 (1999): 564-567.
MACKERSIE, ROBERT C., et al. "Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures." Journal of Trauma-Injury, Infection, and Critical Care 31.4 (1991): 443-451.
Kieninger, Alicia N., et al. "Epidural versus intravenous pain control in elderly patients with rib fractures." The American journal of surgery 189.3 (2005): 327-330.
Moon, M. Ryan, et al. "Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma." Annals of surgery 229.5 (1999): 684.
Jarvis, Amy M., et al. "Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis." OPUS 12 (2009): 50-57.
Scherer, R., et al. "Complications related to thoracic epidural analgesia: a prospective study in 1071 surgical patients." Acta anaesthesiologica scandinavica 37.4 (1993): 370-374.
Kapral, Stephan, et al. "The effects of thoracic epidural anesthesia on intraoperative visceral perfusion and metabolism." Anesthesia & Analgesia 88.2 (1999): 402-406.
With reference to base of skull fractures following trauma:
a) List 5 clinical signs commonly associated with base of skull fractures.
b) List 3 life threatening complications specifically associated with base of skull fractures
c) Briefly outline the role of prophylactic antibiotics in the management of base of skull fractures
a) List 5 clinical signs commonly associated with base of skull fractures.
1) CSF rhinorrhoea
2) CSF otorrhoea
3) Battle’s sign
4) Raccoon eyes
5) Haemotympanum
6) Cranial nerve palsies.
b) List 3 life threatening complications of base of skull fractures
Panhypopituitarism
Basal meningitis
Carotid artery trauma or pseudoaneurysms
Cavernous sinus thrombosis
c) Briefly outline the role of prophylactic antibiotics in the management of base of skull fractures.
BOS # predispose patients to meningitis because of possible direct contact of bacteria in paranasal sinuses, nasopharynx or middle ear with CNS. Also CSF leak is associated with a greater risk of contacting meningitis. Few RCTs exist and the primary end point was a reduction in meningitis.
1) No role for prophylactic antibiotic therapy whether there is CSF leak or not.
2) Do not reduce the risk of meningitis.
Features of base of skull fracture are better covered in Question 14.3 from the second paper of 2010.
Base of skull fracture is also asked about in Question 30.1 from the second paper of 2011.
In brief, the features are:
Complications of a base of skull fracture include the following:
As for the antibiotics; a 1998 meta-analysis had concluded that "antibiotic prophylaxis after basilar skull fractures does not appear to decrease the risk of meningitis." This conclusion was supported bya 2011 Cochrane review.
Pretto, Flores L., C. S. De Almeida, and L. A. Casulari. "Positive predictive values of selected clinical signs associated with skull base fractures." Journal of neurosurgical sciences 44.2 (2000): 77-82.
Tubbs, R. Shane, et al. "William Henry Battle and Battle's sign: mastoid ecchymosis as an indicator of basilar skull fracture: Historical vignette." Journal of neurosurgery 112.1 (2010): 186-188.
Katzen, J. Timothy, et al. "Craniofacial and skull base trauma." Journal of Trauma and Acute Care Surgery 54.5 (2003): 1026-1034.
Samii, Madjid, and Marcos Tatagiba. "Skull base trauma: diagnosis and management." Neurological research 24.2 (2002): 147-156.
Villalobos, Tibisay, et al. "Antibiotic prophylaxis after basilar skull fractures: a meta-analysis." Clinical infectious diseases 27.2 (1998): 364-365.
Ratilal, Bernardo O., et al. "Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures." Cochrane Database Syst Rev 8 (2011).
What do you understand by the term “Damage Control Surgery” (DCS) in relation to abdominal trauma? What important complications may occur following the initial admission to ICU after DCS?
Key feature. Damage Control Surgery involves a 4 phase approach to major emergency abdominal injuries:
• recognition of at risk patient
• Limited, focused surgery for control of haemorrhage and address contamination with temporary abdominal closure,
• restoration of near normal physiology – cardiovascular resuscitation, rewarming (usually active) if hypothermic, correction of coagulopathy (blood products and aFVII) and acidosis. – with optimization of ventilation and
• re laparotomy at 24 – 36 hours with removal of packs, definitive surgery and formal abdominal closure, where possible.
Important complications
New onset or uncontrolled surgical bleeding
Abdominal compartment syndrome (ACS),
inability to wake and wean (open abdomen / planned return to theatre)
missed injuries in the multiply injured patient (need for full examination on admission)
An excellent article on this is available from 2004 (Critical Care Clinics). The topic of damage control surgery is also discussed briefly in the answer to Question 20 from the first paper of 2011. To simplify revision, that answer is replicated below:
Definition:
Rationale:
Key principles:
Complications upon returning to the ICU:
Remember that the patient was not being definitively managed in theatre; if you are lucky they are bleeding slightly less than they were before they went to theatre, but in general the resuscitation is only half-complete. Not only that, but they were probably rushed through the ED, and a secondary survey (or trauma CT) may not have been performed.
Thus, one can anticipate the following:
Morrison, C. Anne, et al. "Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial." Journal of Trauma and Acute Care Surgery 70.3 (2011): 652-663.
Kaafarani, H. M. A., and G. C. Velmahos. "Damage Control Resuscitation In Trauma." Scandinavian Journal of Surgery (2014): 1457496914524388.
Jaunoo, S. S., and D. P. Harji. "Damage control surgery." International Journal of Surgery 7.2 (2009): 110-113.
Schreiber, Martin A. "Damage control surgery." Critical care clinics 20.1 (2004): 101-118.
A 23 year old man is admitted to your intensive care following a near drowning at the local beach. On admission to ICU he has a GCS of 4 and is intubated and ventilated.
a) Briefly list the potential complications from his clinical presentation.
b) What are the risk factors for severe neurological injury?
a) Complications
• Arrhythmia (severe hypothermia)
• Pneumonia
• Aspiration pneumonitis (water, sand, vomit)
• Acute lung injury/ARDS
• Hypoxic encephalopathy
• Multiple organ dysfunction
• Trauma brain injury or other traumatic injuries (particularly at surf beaches or jetties)
• Electrolyte abnormality
b) Risk factors for severe neurological injury
• At scene
o Immersion > 10 minutes
o Delay in CPR commencement
• In the Emergency Department
o Asystole on arrival in ED
o CPR > 25 minutes
o Fixed dilated pupils and GCS< 5
o Fixed dilated pupils and pH < 7.0
• In the ICU
o No spontaneous movements and abnormal brainstem function at 24 hours
o Abnormal CT scan within 36 hours of submersion
The complications from drowning are best expressed as a structured list.
Briefly:
A) - Aspiration of contaminated water or salt water
B) - Pulmonary oedema, atelectasis, poor gas exchange. High risk of pneumonia.
- Possibly, also ARDS due to surfactant loss (seawater submersion)
C) - Hypotension, circulatory collapse, arrhythmia
D) - Hypoxic brain injury
E) - Transient electrolyte disturbance due to even prolonged submersion. Hypothermia
F) - Hypovolemia due to hydrostatic effects of immersion. Renal failure due to global hypoxia.
It would appear the college generally just wanted the candidates to regurgitate the contents of Box 80.1 (page 820) from the "Submersion" chapter by Cyrus Edibam and Tim Bowles.
Paraphrased, the box contains the following risk factors for death or severe neurological injury:
Factors at the site of submersion:
- Immersion for more than 5 minutes
- Delay in CPR of more than 10 minutes
Factors on presentation to the ED
- Fixed dilated pupils
- GCS of 3
Factors after admission to the ICU:
- GCS less than 6
- Arterial pH less than 7.00 upon arrival to ICU
- No spontaneous purposeful movement and the abnormal brainstem function after 48 hours
- Abnormal CT within 36 hours
The risk factors for poor neurological outcome which appear in the college answer suggest that they consider pre-hospital arrest may have occurred in this patient, in which case all the various cardiac arrest associated risk factors also apply.
The the above box, one may also add the following:
Generally, the risk factors for poor neurological recovery after cardiac arrest can be extracted from the massive table which is featured in the answer to Question 4 from the second paper of 2013, "Describe the clinical signs and investigations available to predict poor neurological outcome in comatose survivors of cardiac arrest."
The ARC ALS2 manual (2011) has a section on drowning (pp. 127). This was my main source of information.
Pearn, John. "The management of near drowning." British medical journal (Clinical research ed.) 291.6507 (1985): 1447.
Giammona, Samuel T., and Jerome H. Modell. "Drowning by total immersion: effects on pulmonary surfactant of distilled water, isotonic saline, and sea water." American Journal of Diseases of Children 114.6 (1967): 612-616.
Modell, Jerome H., et al. "Physiologic effects of near drowning with chlorinated fresh water, distilled water and isotonic saline." Anesthesiology 27.1 (1966): 33-41.
Young, Richard SK, Edwin L. Zalneraitis, and Elizabeth C. Dooling. "Neurological outcome in cold water drowning." Jama 244.11 (1980): 1233-1235.
Suominen, Pertti, et al. "Impact of age, submersion time and water temperature on outcome in near-drowning." Resuscitation 52.3 (2002): 247-254.
In a patient hospitalised following a motor vehicle accident,
a) What findings on patient assessment would suggest the presence of traumatic diaphragmatic rupture?
b) Briefly outline the abnormal findings you would seek on rectal examination and their clinical significance if the patient was unconscious.
Diaphragm rupture;
a) Frequently no direct symptoms or signs referable
b) Shoulder pain
c) Left >> right, usually associated with other injuries
d) Intrathoracic bowel
e) Obscured diaphragm shadow on CXR
f)_If delayed presentation – post prandial epigastric or thoracic pain
g) Rarely gastric herniation or volvulus
Rectal examination:
a. Absent anal tone - cord lesion (unless relaxants administered)
b. Palpable sphincter rupture
c. Displaced (high riding) prostate – ruptured urethra
d. High tenderness in anterior quadrants – ruptured viscus e. Pelvic haematoma – pelvic fracture
f. Palpable bony disruption – sacro-coccygeal / pelvic fracture
g. Visible external lacerations / bleeding.
Traumatic diaphragmatic rupture is usually pretty obscure.
Radiological findings are usually all the findings you get. The CXR is usually diagnostic.
However, one can occasionally unearth some of the following (non-specific) clinical features:
As for the rectal examination; one looks for
According to a recent review, the PR changed management in 1.2% of observed cases.
LITFL have some choice words about this investigation.
García-Navarro, Ana, et al. "[Traumatic diaphragmatic rupture]." Cirugia espanola 77.2 (2005): 105-107.
Morley, J. E. "Traumatic diaphragmatic rupture." Hospital 30.80 (1974): 1.
Willsher, Peter C., and Richard J. Cade. "Traumatic diaphragmatic rupture."Australian and New Zealand Journal of Surgery 61.3 (1991): 207-210.
Simpson, J., et al. "Traumatic diaphragmatic rupture: associated injuries and outcome." Annals of the Royal College of Surgeons of England 82.2 (2000): 97.
Porter, John M., and Caesar M. Ursic. "Digital rectal examination for trauma: does every patient need one?." The American surgeon 67.5 (2001): 438-441.
List 5 clinical signs of fractured base of skull following a motor vehicle accident.
1. Raccon eyes
2. Battle’s sign
3. CSf rhinorrhoea
4. CSF otorrhoea
5. Hemotympanum
6. Lower cranial nerve palsies
This question is very similar to Question 14.3 from the second paper of 2010 and Question 30.1 from the second paper of 2011.
You are asked to review a 64 year old man who has been brought to the emergency department having been burned in a house fire. There is no coherent history available from the patient and you observe that he is drowsy and confused, and, has a persistent cough. His heart rate is 120 bpm, blood pressure 88/52 mmHg, respiratory rate 28 and oxygen saturations are 94 % on high flow oxygen via a non re-breather mask.
30.1 List the initial priorities in management.
30.2 What features on history and examination would suggest a significant airway injury?
30.3 Give a differential diagnosis for his conscious level.
You are asked to review a 64 year old man who has been brought to the emergency department having been burned in a house fire. There is no coherent history available from the patient and you observe that he is drowsy and confused, and, has a persistent cough. His heart rate is 120 bpm, blood pressure 88/52 mmHg, respiratory rate 28 and oxygen saturations are 94 % on high flow oxygen via a non re-breather mask.
30.1 List the initial priorities in management.
1) Resuscitation including primary and secondary survey
2) Assessment and management of potential airway burn injury – mention consideration of early intubation, not cutting ET tubes and avoiding nasal tubes.
3) Obtain large bore iv access and administration of fluid bolus (20mls/kg) for probable hypovolaemic shock- mention that groins are usually spared in burns and are a good site for clean skin vas cath access.
4) Look for signs of traumatic injury and assess extent of body surface area and depth of burn
5) Awareness of risk of hypothermia
6) Seek collateral history for past medical history and medication history and history of acute events
30.2 What features on history and examination would suggest a significant airway injury?
1. Burns occurring in a closed space
2. Cough, stridor, hoarseness of voice
3. Burns to face, lips, mouth, pharynx or nasal mucosa
4. Soot in sputum, nose or mouth
5. Hypoxaemia or dyspnoea
6. Carboxyhaemoglobin levels > 2%
7. Acute confusional state or depressed level of consciousness
30.3 Give a differential diagnosis for his conscious level.
1. Traumatic brain injury
2. Carbon monoxide / CN - poisoning
3. Alcohol intoxication/drug overdose
4. Other pathology precipitating loss of consciousness eg stroke, intracranial haemorrhage, seizure-related, hypoglycaemia
This question is identical to Question 11 from the first paper of 2013, and closely resembles Question 28 from the second paper of 2010 (except in 2010 the 64 year old male mutated into a three year old child).
1) With respect to the clinical assessment of a patient presenting with a severe burn injury sustained in a house fire:
a) Outline how burns are classified.
b) List three methods for estimating the total body surface area affected by a burn injury.
c) Other than the burn type and extent, list the other important features of the physical examination that should be noted as part of the initial clinical assessment of the patient described above.
a) Outline how burns are classified.
Burns are classified by depth of injury.
Superficial (formerly first degree):
• Epidermis only
Partial Thickness (formerly second degree):
• Superficial
• Deep
Full Thickness (formerly third degree)
• All layers of dermis and may involve underlying tissue
b) List three methods for estimating the total body surface area affected by a burn injury.
• Lund-Browder Chart
• The Rule of Nines
• The Rule of Palm
c) Other than the burn type and extent, list the other important features of the physical examination that should be noted as part of the initial clinical assessment of the patient described above.
• Basic resuscitation status: Airway patency, Breathing, Circulatory status, Conscious level
• Adequacy of resuscitation to date: heart rate, blood pressure, urine output
• Evidence of associated trauma
• Evidence of airway burn and inhalational injury: stridor, burns around nose and mouth, carbonaceous sputum
• Presence of facial and/or corneal burns, perineal burns
• Presence of circumferential burns, evidence of extremity compartment syndrome, ventilator inadequacy
• Evidence of rhabdomyolysis
• Evidence of inhalation of toxic gases eg CO
• Temperature
• Adequacy of analgesia
• Potential problems with vascular access
• Evidence of drug / alcohol ingestion and/or co-morbid conditions eg epilepsy
a) Outline how burns are classified.
Little can be added to the college answer, as it is a fairly straightforward question. The table below comes from the Clinical Practice Guidelines of the Royal Children's Hospital in Melbourne.
Depth |
Cause |
Surface/colour |
Pain sensation |
Superficial |
Sun, flash, minor scald |
Dry, minor blisters, erythema, brisk capillary return |
Painful |
Partial thickness-superficial (superficial dermal) |
Scald |
Moist, reddened with broken blisters, brisk capillary return |
Painful |
Partial thickness- deep (deep dermal) |
Scald, minor flame contact |
Moist white slough, red mottled, sluggish capillary return |
Painless |
Full thickness |
Flame, severe scald or flame contact |
Dry, charred whitish. Absent capillary return |
Painless |
b) List three methods for estimating the total body surface area affected by a burn injury.
The college gives the following three methods:
c) Other than the burn type and extent, list the other important features of the physical examination that should be noted as part of the initial clinical assessment of the patient described above.
The assessment of a burns patient is covered in greater detail by the BMJ series.
The BMJ had published a series of 12 articles, titled "the ABC of burns". These are a valuable resource.
PRUITT Jr, BASIL A., DARYL R. ERICKSON, and ALAN MORRIS. "Progressive pulmonary insufficiency and other pulmonary complications of thermal injury."Journal of Trauma and Acute Care Surgery 15.5 (1975): 269-379.
Hettiaratchy, Shehan, and Remo Papini. "Initial management of a major burn: II—assessment and resuscitation." Bmj 329.7457 (2004): 101-103.
Hettiaratchy, Shehan, and Peter Dziewulski. "Pathophysiology and types of burns." Bmj 328.7453 (2004): 1427-1429.
Ansermino, Mark, and Carolyn Hemsley. "Intensive care management and control of infection." Bmj 329.7459 (2004): 220-223
A 78 year old female is admitted to the ICU following a motor vehicle collision. She has sustained multiple left sided rib fractures, pulmonary contusion and has severe pain.
Outline the relative advantages and disadvantages of thoracic epidural analgesia compared to systemic opioid analgesia via a PCA (Patient Controlled Analgesia) for her pain management.
Thoracic epidural |
Systemic opiates via PCA |
|
Advantages |
• Can provide excellent analgesia |
• Staff very familiar with use |
Disadvantages |
• Requires skill for placement |
• Increasing age associated with increasing adverse effects from opiates, especially bowel dysfunction, nausea, drowiness |
The college table is well organised, and little can be added to it, other than some literature references. In summary, a couple of biggish meta-analysis papers from 2009 both discovered the following key features:
Thus:
Thoracic epidural |
Systemic opiates via PCA |
|
Advantages |
|
Staff very familiar with use |
Disadvantages |
|
• Increasing age associated with increasing adverse effects from opiates, especially bowel dysfunction, nausea, drowiness |
Wu, Christopher L., et al. "Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash." Journal of Trauma-Injury, Infection, and Critical Care 47.3 (1999): 564-567.
MACKERSIE, ROBERT C., et al. "Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures." Journal of Trauma-Injury, Infection, and Critical Care 31.4 (1991): 443-451.
Kieninger, Alicia N., et al. "Epidural versus intravenous pain control in elderly patients with rib fractures." The American journal of surgery 189.3 (2005): 327-330.
Moon, M. Ryan, et al. "Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma." Annals of surgery 229.5 (1999): 684.
Jarvis, Amy M., et al. "Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis." OPUS 12 (2009): 50-57.
This clinical sign was noted in a patient involved in a motor vehicle accident.
a) What sign is shown below?
b) What does it indicate?
c) What associated signs support the diagnosis mentioned in Question 14.3 b?
A clinical photograph of Battle’s sign was supplied.
b) What does it indicate?
Base of skull fracture
c) What associated signs support the diagnosis mentioned in Question 14.3 b?
• CSF otorrhoea
• Haemotympanum
• Racoon eyes
• CSF rhinorrhoea
• Cranial nerve abnormalities
This image was misappropriated from the ACI website ( NSW Agency for Clinical Innovation).
Battle's sign (named after Dr William Henry Battle, rather than any association with warfare) apparently has a 100% positive predictive value for base of skull fracture.
Features associated with a base of skull fracture include several features which the college did not mention. I have tagged them on to the end of their list, for completeness:
Pretto, Flores L., C. S. De Almeida, and L. A. Casulari. "Positive predictive values of selected clinical signs associated with skull base fractures." Journal of neurosurgical sciences 44.2 (2000): 77-82.
Tubbs, R. Shane, et al. "William Henry Battle and Battle's sign: mastoid ecchymosis as an indicator of basilar skull fracture: Historical vignette." Journal of neurosurgery 112.1 (2010): 186-188.
Katzen, J. Timothy, et al. "Craniofacial and skull base trauma." Journal of Trauma and Acute Care Surgery 54.5 (2003): 1026-1034.
Samii, Madjid, and Marcos Tatagiba. "Skull base trauma: diagnosis and management." Neurological research 24.2 (2002): 147-156.
You have been asked to review a three year old child who was trapped in a house fire and is now in the Paediatric Emergency Department. There is no history available from the child’s carer and you observe that the child is drowsy and confused and has a persistent cough. His heart rate is 140 beats per minute, blood pressure 70/40 mmHg. Respiratory rate is 54 breaths per minute and oxygen saturations are 94 % on high flow oxygen via a non re- breather mask.
a. Briefly outline the initial priorities in management.
b. List the features from the history and your examination of this child which would suggest a significant airway injury.
c. List 4 likely causes for his altered conscious state.
a. Briefly outline the initial priorities in management.
• Resuscitation including primary and secondary survey
• Assessment and management of potential airway burn injury – mention consideration of early intubation,
• Obtain large bore iv access and administration of fluid bolus (20mls/kg) for probable hypovolaemic shock- mention that groins are usually spared in burns and are a good site for clean skin vas cath access.
• Look for signs of traumatic injury and assess extent of body surface area and depth of burn
• Awareness of risk of hypothermia
• Seek collateral history for past medical history and medication history and history of acute events
b. List the features from the history and your examination of this child which would suggest a significant airway injury.
• Burns occurring in a closed space
• Cough, stridor, hoarseness of voice
• Burns to face, lips, mouth, pharynx or nasal mucosa
• Soot in sputum, nose or mouth
• Hypoxaemia or
• Dyspnoea
• Carboxyhaemoglobin levels > 2%
• Acute confusional state or depressed level of consciousness
c. List 4 likely causes for his altered conscious state.
• Traumatic brain injury
• Carbon monoxide / CN – poisoning
• Hypoxic insult
• Other pathology precipitating loss of consciousness eg seizure-related, hypoglycaemia, drug ingestion
This question - though posing as a question about a paediatric patient - closely resembles Question 11 from the first paper of 2013, where the candidates were asked exactly the same series of questions about a slightly singed 64 year old male.
“Damage control resuscitation” as applied to the management of the major trauma patient integrates permissive hypotension, haemostatic resuscitation and damage control surgery.
Outline the key principles of each of these three strategies, including the rationale.
a. Permissive hypotension
b. Haemostatic resuscitation
c. Damage control surgery
“Damage control resuscitation” as applied to the management of the major trauma patient integrates permissive hypotension, haemostatic resuscitation and damage control surgery.
Outline the key principles of each of these three strategies, including the rationale.
a. Permissive hypotension
1. Keep SBP low enough to avoid exsanguination but high enough to maintain perfusion.
2. Relates to disruption of an unstable clot by higher pressures and worsening of bleeding.
b. Haemostatic resuscitation
i. Correct hypothermia
1. Decreases platelet responsiveness.
2. Increases platelet sequestration in liver and spleen
3. Reduces Factor function eg Factors XI and XII
4. Alters fibrinolysis
ii. Correct acidosis
1. pH strongly effects activity of Factors V, VIIa and X.
2. Acidosis inhibits thrombin generation
3. Cardiovascular effects of acidosis (pH <7.2) – decreased contractility and CO, vasodilatation and hypotension, bradycardia and increased dysrhythmias.
iii. Treat coagulopathy early and aggressively
1. Many coagulopathic changes occur early after trauma, therefore need to correct early.
2. Use much higher FFP to PRBC ratios (1:1/2:3) than previously used. Is associated with improved survival.
3. Higher platelet to PRBC transfusion ratios also becoming more popular but evidence is less clear.
4. Cryoprecipitate provides an additional option for Factor replacement for a lower volume of fluid.
5. rFVIIa has been used in trauma, but off label and anecdotally.
iv. The use of blood products instead of isotonic crystalloid fluid aiming for limited volume replacement
1. Large volume crystalloids can lead to dilutional coagulopathy and exacerbate bleeding.
2. Crystalloids have no O2 carrying capacity and do little to correct the anaerobic metabolism and O2 debt associated with shock.
3. Need less volume of blood product therefore likely to be less tissue and organ (eg lung, small intestine mucosa) oedema and failure (eg pulmonary oedema, abdominal compartment syndrome)
4. Hypertonic saline is another option (proven restored microvascular flow, decreased tissue oedema, attenuated inflammatory response).
c. Damage control surgery
1. Management of the metabolic derangement of ongoing bleeding supersedes the need for definitive surgery
2. Abbreviated operations that control haemorrhage and contain spillage from the alimentary and urogenital tracts.
3. Rapid transfer to ICU for correction of acidosis, coagulopathy and hypothermia
4. Definitive operation is deferred.
5. These operations tend to have a high complication rate
6. Survival is given preference over morbidity.
Definition:
Rationale:
Key principles:
Definition:
Rationale:
Key principles:
An excellent article on this is available from 2004 (Critical Care Clinics)
Definition:
Rationale:
Key principles:
Morrison, C. Anne, et al. "Hypotensive resuscitation strategy reduces transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial." Journal of Trauma and Acute Care Surgery 70.3 (2011): 652-663.
Kaafarani, H. M. A., and G. C. Velmahos. "Damage Control Resuscitation In Trauma." Scandinavian Journal of Surgery (2014): 1457496914524388.
Jaunoo, S. S., and D. P. Harji. "Damage control surgery." International Journal of Surgery 7.2 (2009): 110-113.
Schreiber, Martin A. "Damage control surgery." Critical care clinics 20.1 (2004): 101-118.
A 58-year-old man returns from theatre following an emergency splenectomy after a motorcycle accident. A secondary trauma survey reveals that he has suffered left sided rib fractures and a right compound tibial fracture. On admission to the intensive care unit, he is sedated, intubated and ventilated, hypotensive (80/40 mmHg), has a tachycardia (140 beats per minute) and is cool peripherally.
a) List the likely causes of this man's shock state.
b) List the clinical features that would help distinguish between these likely causes.
c) What echocardiographic features are associated with the causes you have described?
a) List the likely causes of this man's shock state.
b) List the clinical features that would help distinguish between these likely causes
c) What echocardiographic features are associated with the causes you have described?
This is a question about the different causes of shock in trauma, and their relevant features, with a focus on the early use of ultrasound.
Questions a) and b) clearly favour the candidate who has recently done the EMST and is familiar with the ATLS manual, which is the best source for this sort of thing. I made my own summaries when I did that course.
Because questions a) and b) are rather straightforward, I will focus more on the echocardiographic investigation of shock in trauma.
A certain James Lai (FRCA, FANZCA) has published a brilliant set of slides for public delectation, which does this topic justice.
A 2011 study has also demonstrated that fluid assessment can be carried out quickly and effectively using IVC diameter and IVC respiratory variation, although in this study a surgical intensivist or an ultrasonographer (rather than an ED registrar) were performing the study. To address this concern, the same group later demonstrated that even a shaved ape could be trained to perform a limited goal-directed TTE.
Interestingly, there are also many studies of transoesophageal echo in trauma. One is tempted to salute the bravery of the man who would jam a TOE probe down into a trauma patient. However, it certainly seems to be helpful. A study comparing transthoracic and trasoesophageal assessment has demonstrated that TOE is significantly more accurate, and that TTE in severe chest trauma usually gives unsatisfactory images.
Ferrada, Paula, et al. "Transthoracic focused rapid echocardiographic examination: real-time evaluation of fluid status in critically ill trauma patients."Journal of Trauma and Acute Care Surgery 70.1 (2011): 56-64.
Ferrada, Paula, et al. "Limited transthoracic echocardiogram: so easy any trauma attending can do it." Journal of Trauma and Acute Care Surgery 71.5 (2011): 1327-1332.
Chirillo, Fabio, et al. "Usefulness of transthoracic and transoesophageal echocardiography in recognition and management of cardiovascular injuries after blunt chest trauma." Heart 75.3 (1996): 301-306.
a) What clinical sign is illustrated here?
b) What does this indicate?
c) List 2 other clincal signs which may be present which might support your answer in b?
a) What clinical sign is illustrated here?
Racoon or Panda eyes
b) What does this indicate?
Frontal base of skull fracture
c) List 2 other clincal signs which may be present which might support your answer in b?
Haemotympanum
CSF rhinorrohea or otorrhoea.
I shall not waste too much time on this; only to point out that these signs have a very high positive predictive value for the presence of fractures and intracranial lesions.
Features of base of skull fracture are better covered in Question 14.3 from the second paper of 2010.
Herbella, Fernando AM, et al. "‘Raccoon Eyes’(periorbital haematoma) as a sign of skull base fracture." Injury 32.10 (2001): 745-747.
Pretto, Flores L., C. S. De Almeida, and L. A. Casulari. "Positive predictive values of selected clinical signs associated with skull base fractures." Journal of neurosurgical sciences 44.2 (2000): 77-82.
This patient presented is admitted to your ICU with respiratory failure following a motor vehicle accident. The following clinical sign (see picture below) were present on examination of the patient.
(image link is from www.springerimages.com)
a) What clinical sign is illustrated in this picture?
b) What is the likely cause of the respiratory failure?
a) What clinical sign is illustrated in this picture?
Conjunctival petechiae
b) What is the likely cause of the respiratory failure?
Fat embolism syndrome
This question depicts a well known clinical sign and does not require a massive amount of cognitive effort.
Fat embolism syndrome has well-described features, and most people will connect trauma, breathing difficulty and conjunctival petechii. Fat rises, and the petechii appear on whatever the uppermost bodypart happens to be.
Gurd, Alan R., and R. I. Wilson. "The fat embolism syndrome." Journal of Bone & Joint Surgery, British Volume 56.3 (1974): 408-416.
Tachakra, S. S. "Distribution of skin petechiae in fat embolism rash." The Lancet 307.7954 (1976): 284-285.
Outline the initial management of a 62-year-old male presenting with haemorrhagic shock secondary to pelvic fractures following a fall from a ladder.
Life-threatening situation and management involves a multi-disciplinary approach following EMST guidelines.
This question would benefit from a systematic approach.
Supportive management:
A) Assessment of the airway and of the need for immediate intubation, while maintaining C-spine precautions
B) Ventilation with high FiO2; investigation of possible aspiration with CXR and ABG.
C) Establishment of IV access and correction of hypovolemia;
urgent collection of a sample for a crossmatch of blood and urgent administration of available uncrossmatched blood.
Assess for retroperitoneal and pelvic bleeding with FAST +/- CT
D) Investigate causes of fall related to intracranial events, eg. ICH,
intoxication, seizure, etc.
E)Correct hypothermia, hypocalcemia and acidosis
Specific management:
Ensure haemostasis; the following options are available
What say the literature? This 2007 article essentially echoes the suggestions made by the college.
ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma
Geeraerts, Thomas, et al. "Clinical review: initial management of blunt pelvic trauma patients with haemodynamic instability." Critical Care 11.1 (2007): 204.
Heetveld, Martin J., et al. "Hemodynamically unstable pelvic fractures: recent care and new guidelines." World journal of surgery 28.9 (2004): 904-909.
Martinelli, Thomas, et al. "Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures." Journal of Trauma and Acute Care Surgery 68.4 (2010): 942-948.
Douma, Matthew, Katherine E. Smith, and Peter G. Brindley. "Temporization of Penetrating Abdominal-Pelvic Trauma With Manual External Aortic Compression: A Novel Case Report." Annals of emergency medicine (2013).
In patients suffering from major burns, outline the possible physiologic derangements and their underlying mechanisms that could contribute to problems of oxygenation and ventilation.
Can affect 4 anatomic areas of the respiratory tract:
Supraglottal, tracheobronchial, and pulmonary parenchymal, and chest/abdominal wall.
Derangements include:
1. Supraglottal
Loss of airway patency due to mucosal oedema
Loss of airway reflexes due to coma (e.g. blast Traumatic brain injury, intoxications such as carbon monoxide,)
2. Tracheobronchial
Bronchospasm resulting from inhaled irritants
Mucosal oedema and endobronchial sloughing causing small airway occlusion, leading to intrapulmonary shunting.
3. Pulmonary Parenchymal
Pulmonary (alveolar) oedema and collapse leading to decreased compliance, and further intrapulmonary shunting.
Loss of tracheobronchial epithelium and airway ciliary clearance contributing to tracheobronchitis and pneumonia.
Barotrauma, ARDS, pleural effusions, Ventilator associated pneumonia, TRALI and tracheobronchitis may all result from Intensive Care resuscitation, and treatments of the above.
4. Mechanical
Circumferential full thickness burns of the chest and abdomen may cause reduced static compliance resulting in restrictive ventilator defect, made worse by large volumes of oedema with fluid resuscitation and capillary leak.
5. Other
Toxic inhalation of carbon monoxide (CO) resulting in a left shift of the ODC and oxygen transport capacity (Carboxy Hb) and decreased cellular oxidative processes.
Other toxic gases NH3, HCL – pulmonary oedema,mucosal irritation and ALI CN- poisoning, cellular hypoxia
Increased metabolic requirements may overwhelm a respiratory system already impaired by all the above.
This question asks, "what are the influences of smoke inhalation on respiratory function and gas exchange?" The college has decided to divide their answer anatomically. An equally valid systematic approach could see the candidate divide this issue into ventilation, diffusion, shunting and oxygen transport.
Ventilation
Diffusion
Shunting
Oxygen transport
Enkhbaatar, Perenlei, and Daniel L. Traber. "Pathophysiology of acute lung injury in combined burn and smoke inhalation injury." Clinical Science 107.2 (2004): 137-144.
Whitener, D. R., et al. "Pulmonary function measurements in patients with thermal injury and smoke inhalation." The American review of respiratory disease 122.5 (1980): 731-739.
Crapo, Robert O. "Smoke-inhalation injuries." JAMA 246.15 (1981): 1694-1696.
A 42-year-old primigravida, 30 weeks gestation, is admitted with abdominal trauma and hypotension, following a motor vehicle crash, to the Emergency Department of a hospital without an obstetric service.
Outline the management issues specific to the care of this patient.
In addition to management by a trauma team following EMST principles, this case requires additional early obstetric, neonatal and anaesthetic input. The operating theatre needs to be alerted to the possibility of the need for emergency Caesarian section. In an elderly primigravida this is likely to be a ‘precious’ pregnancy.
Other specific management issues include:
High flow oxygen to avoid maternal and fetal distress. Reduced respiratory reserve with decreased FRC. Potential for relative difficulty in intubation
Maternal compensation for blood loss is at the expense of utero-placental blood flow. Left lateral tilt to avoid aorto-caval compression.
Transfusion should be Rhesus compatible and immunoglobulin should be given if she is Rhesus negative because of the immunological effects of minor feto-maternal haemorrhage.
Physiological anaemia of pregnancy
Minimise exposure to radiation – ultra-sound alternatives may be preferable. (DPL contra-indicated).
Retroperitoneal haemorrhage, placental abruption or fetal distress may occur and premature labour may be precipitated.
If pelvic fractures present, pelvic binders may not be suitable. Regular fetal monitoring is required.
Bereavement issues in the event of an adverse fetal outcome
This question forms a part of the "manage this pregnant trauma patient" spectrum of fellowship questions. For a general reference, one is directed to Question 3 from the first paper of 2007 (Outline the special considerations involved in the care of a pregnant patient involved in multi-trauma.). Specific features of severe multi-trauma in pregnancy can also be found on the page dedicated to this topic.
In summary:
Issues to consider in investigations and the secondary survey
Oh's Intensive Care manual: Chapter 64 (pp. 684) General obstetric emergencies by Winnie TP Wan and Tony Gin
Soar, Jasmeet, et al. "European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution." Resuscitation 81.10 (2010): 1400-1433.
Mattox, Kenneth L., and Laura Goetzl. "Trauma in pregnancy." Critical care medicine 33.10 (2005): S385-S389.
DROST, THOMAS F., et al. "Major trauma in pregnant women: maternal/fetal outcome." Journal of Trauma-Injury, Infection, and Critical Care 30.5 (1990): 574-578.
A 28-year-old man has been referred to the intensive care unit for management after being pulled from a house fire.
Briefly describe the injury shown below in figure 1:
a)
b)
c)
Important clinical features
It is incredibly difficult to find an image of a burned left lower leg on Google which features the precise injuries which were described by the college answer. The best I could do is the above image of a couple of burned legs, retrieved without any permission whatsoever from an EMSWorld article on burns care. The picture itself is credited to Dr James H. Holmes IV, Burn Center Director Wake Forest University Baptist Health. The caption describes it as "Thermal burn injury involving anterior of both legs, uninjured areas include where shorts, socks and shoes provided partial protection. This is a 15% TBSA burn. Each leg, including the foot, is 18%. For this burn, the anterior surface of each leg, minus the area of the foot and the upper leg shielded by clothing, is approximately 15%. The patient is pictured following debridement upon admission at a burn center".
The possible complications of such a burn? One struggles to add anything to the already complete list provided by the college.
What are other important features on the initial clinical assessment of this patient?
This answer should follow some sort of system.
A) - Airway burns
B) - Carbon monoxide or cyanide poisoning
C) - Hypotension, hypovolemia, adequacy of fluid resuscitation;
- problems gaining vascular access
D) - Decreased level of consciousness, head injury; analgesia
E) - Electrolyte disturbance
- Exposure and assessment of total burned areas
F) - Urine output
The BMJ had published a series of 12 articles, titled "the ABC of burns". These are a valuable resource.
PRUITT Jr, BASIL A., DARYL R. ERICKSON, and ALAN MORRIS. "Progressive pulmonary insufficiency and other pulmonary complications of thermal injury."Journal of Trauma and Acute Care Surgery 15.5 (1975): 269-379.
Hettiaratchy, Shehan, and Remo Papini. "Initial management of a major burn: II—assessment and resuscitation." Bmj 329.7457 (2004): 101-103.
Hettiaratchy, Shehan, and Peter Dziewulski. "Pathophysiology and types of burns." Bmj 328.7453 (2004): 1427-1429.
Ansermino, Mark, and Carolyn Hemsley. "Intensive care management and control of infection." Bmj 329.7459 (2004): 220-223.
You are called to assist with a 12-year-old child, brought in to the Emergency Department unconscious, following near drowning at a local beach.
Outline your immediate management.
Assess for signs of life and if absent commence CPR, check underlying rhythm and treat appropriately following APLS guidelines
Airway and breathing Administer 100% oxygen
Intubation for airway protection and suction with ETT cuffed size 7 (ILCOR guidelines – cuffed ETT’s acceptable in children) (age/4 +4) (half size bigger and smaller available) with C spine precautions
Ventilate with appropriate settings (Vt 6-8ml/kg, RR 15-20, PEEP > 5cm H2O) SpO2 and ETCO2 monitoring, ABG and CXR
May get some discussion re management of ARDS
Circulation
Assess pulse rate and volume, blood pressure and capillary return, Doppler may be helpful if hypothermic
Secure IV access
If inadequate circulation fluid bolus of 20 ml/kg 0.9% Saline – avoid hypotonic intravenous fluids
Consider inotrope support early Blood glucose, FBE, U & E
Cerebral support
Avoid any further episodes of hypoxia and hypercarbia
Optimise circulation
Temperature
Actively rewarm to core temperature of 34oC Passively rewarm over 34oC
If post cardiac arrest – maintain hypothermia 32.5 – 33.5oC for > 24 hours
Other
Primary and secondary survey for associated trauma
Look for precipitating cause (hypoglycaemia, epilepsy, drug/alcohol ingestion, marine envenomation)
Antibiotics not indicated routinely
Collateral history – immersion time, resuscitation at scene, medical history Admit to ICU with appropriate paediatric expertise
Counsel family regarding likely outcomes
This question would benefit from a systematic answer. The college answer is already quite systematic; there is little that can be added to it without this turning into an unmanageably long discussion.
First step: assess for signs of life/confirm cardiac arrest.
If cardiac arrest is confirmed, follow the pediatric ALS algorithm.
Next step: Primary survey;
Important pre-hospital issues
Emergency management issues
ICU management issues
The ARC ALS2 manual (2011) has a section on drowning (pp. 127). This was my main source of information.
Pearn, John. "The management of near drowning." British medical journal (Clinical research ed.) 291.6507 (1985): 1447.
Define the following terms:
(iii) IPP = MAP – IAP
Cardiac
Decreased cardiac output –
Hypotension – decreased cardiac output.
Respiratory
A slightly less formal discussion of abdominal compartment syndrome takes place in Question 21from the second paper of 2006: "Outline the causes, consequences and the management of abdominal compartment syndrome. "Brief notes on the pathophysiology of abdominal compartment pressure and its measurement are available, with references for the time-rich exam candidate.
First, the definitions. These are derived from a 2011 consensus statement, from which much of the below information is derived.
Specifically, the definitions were copied verbatim from Table 1, "Consensus definitions list"; one might notice that they are identical to the college answer.
Intra-abdominal Hypertension (IAH)
A sustained or repeated pathological elevation in IAP ≥ 12 mmHg
Abdominal Compartment Syndrome (ACS)
A sustained IAP> 20 mmHg (with or without an APP < 60 mmHg) that is associated with new organ dysfunction/failure
Abdominal Perfusion Pressure (APP)
APP = MAP − IAP.
Measurement of intra-abdominal pressure
List the adverse cardiorespiratory effects of an increase in IAP in a mechanically ventilated patient and outline the physiological mechanisms that account for these effects.
The college demands we focus on the cardiorespiratory consequences.
Thus:
Oh's Intensive Care manual: Chapter 45 (pp. 520) Abdominal surgical catastrophes by Stephen J Streat
Malbrain, Manu LNG, et al. "Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. I. Definitions." Intensive care medicine 32.11 (2006): 1722-1732.
Cheatham, Michael L., et al. "Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension." Journal of Trauma-Injury, Infection, and Critical Care 49.4 (2000): 621-627.
Bailey, Jeffrey, and Marc J. Shapiro. "Abdominal compartment syndrome."Critical Care 4.1 (2000): 23.
Cheatham, Michael Lee. "Abdominal compartment syndrome." Current opinion in critical care 15.2 (2009): 154-162.
Maerz, Linda, and Lewis J. Kaplan. "Abdominal compartment syndrome."Critical care medicine 36.4 (2008): S212-S215.
Saggi, Bob H., et al. "Abdominal compartment syndrome." Journal of Trauma-Injury, Infection, and Critical Care 45.3 (1998): 597-609.
You are asked to review a 64-year-old male who has been brought to the Emergency Department having been burned in a house fire. He is drowsy and confused with a persistent cough and unable to give a coherent history. His heart rate is 120 beats/minute, blood pressure is 88/52 mmHg, respiratory rate is 28 breaths/min and oxygen saturation is 94% on high flow oxygen via a reservoir mask.
A structured answer to (a) would resemble the following:
A) Assessment of the airway and of the need for immediate intubation
B) Ventilation with high FiO2; investigation of possible carbon monoxide poisoning with ABG, and investigation for pulmonary thermal injury with CXR.
C) Establishment of secure vascular access, and the administration of crystalloid to replace intravascular volume.
The college wanted a specific mention of the groins as regions which are frequently spared in house fires. I presume this excludes those fires which started in the groin.
D) Adequate analgesia and sedation
Features suggestive of airway burns:
A BMJ article from the "ABC of burns" series contains Table 1, "Warning signs of airway burns", which I reproduce below:
This table, with minimal modification, seems to form the basis of the college answer.
Other differentials for a decreased level of consciousness in a burned trauma patient include the following:
Burn and trauma-associated:
Generic differentials:
Many others could be generated. Maybe this guy was assaulted, and then left for dead in a shed which was set ablaze as a forensic countermeasure.
The BMJ had published a series of 12 articles, titled "the ABC of burns". These are a valuable resource.
PRUITT Jr, BASIL A., DARYL R. ERICKSON, and ALAN MORRIS. "Progressive pulmonary insufficiency and other pulmonary complications of thermal injury."Journal of Trauma and Acute Care Surgery 15.5 (1975): 269-379.
Hettiaratchy, Shehan, and Remo Papini. "Initial management of a major burn: II—assessment and resuscitation." Bmj 329.7457 (2004): 101-103.
Cartotto, Robert C., et al. "How well does the Parkland formula estimate actual fluid resuscitation volumes?." Journal of Burn Care & Research 23.4 (2002): 258-265.
Ansermino, Mark, and Carolyn Hemsley. "Intensive care management and control of infection." Bmj 329.7459 (2004): 220-223.
Michielsen, Dirk PJ, and Cynthia Lafaire. "Management of genital burns: a review." International journal of urology 17.9 (2010): 755-758.
A 53-year-old male presents following a motor vehicle accident. He complains of severe abdominal pain but has no chest or long bone injuries. He has previously had a mechanical mitral valve replacement. His medications include warfarin.
The following image is a slice from his CT body scan.
a) List the abnormalities on the CT scan image.
b) Outline the advantages and disadvantages of CT scanning in the assessment of blunt abdominal trauma.
c) Outline your immediate management of his coagulation state.
a)
b)
c)
Competing interests of life-threatening haemorrhage and need for anticoagulation (MVR) and in this instance haemorrhage is greater risk
Cease warfarin therapy and give:
Vitamin K 5 – 10 mg IV (recommended in Australian guidelines but controversial as may cause resistance when warfarin needs re-starting. Balance of risks and lower dose may be preferable)
AND
Prothrombin complex concentrate (Prothrombinex-VF) 50 IU/kg AND
Fresh frozen plasma 150 – 300 ml OR If PCC not available
FFP 15 ml/kg
Tranexamic acid as soon as possible
Other blood products (packed cells, platelets, cryoprecipitate) as indicated Titrate therapy against measurement of coagulopathy (APTT, PT, fibrinogen, platelets)
TEG if available
Prevent / correct hypothermia, acidosis, hypocalcaemia
The image above is not from the original exam paper, but rather stolen shamelessly fromRadiopedia.org. It represents a large laceration in the right lobe of the liver, with a perihepatic hematoma.
Now, as for the advantages and disadvantages of CT in blunt abdominal trauma;
a good recent article discusses these points as well as offering tables of injury severity grading.
As for the corection of coagulopathy; the answer should at least include the competition between the need for anticoagulation and the need for haemostasis. If one bleeds to death, one's circulation will cease and with blood stagnating in the left atrium those valve leaflets will get clot on them anyway, so perhaps the haemostasis is a priority.
The discussion of haemostasis in this patient can be divided into two subtopics: what to do about the warfarin, and what generic strategies are there to achieve medical haemostasis in a trauma patient.
Reversal of warfarin anticoagulation
A generic discussion of warfarin reversal guidelines takes place in another chapter, and Question 15.1 from the second paper of 2011 deals with the reversal of warfarin in a patient with a suprathereapeutic INR.
In brief, this is a warfarinised patient with clinically significant bleeding, and thus it does not matter what his INR is. The most recent guidelines suggest the following multi-agent strategy:
Medical haemostasis in major trauma
The use of tranexamic acid in trauma is also well-established, and one would administer 1g of this substance immediately.
The college points out that TEG would be the ideal means of assessing the coagulation system (and fibrinolysis), but this is still being debated. If TEG is not available (and it is infrequently available) then PT APTT and fibrinogen levels would guide one's resuscitation.
There is widespread disagreement as to what proportion to give; typically one is guided by the volume of blood transfused and by the changes in coagulation parameters.
Ultimately, one might arrive at a situation where Factor VIIa is pulled out, in spite of this being an off-license use of this product. This controversy is better discussed in Question 12 from the first paper of 2007, where the college invites us to "white short notes" about it.
Fang, Jen-Feng, et al. "Usefulness of multidetector computed tomography for the initial assessment of blunt abdominal trauma patients." World journal of surgery 30.2 (2006): 176-182.
Soto, Jorge A., and Stephan W. Anderson. "Multidetector CT of blunt abdominal trauma." Radiology 265.3 (2012): 678-693.
Ross I Baker, Paul B Coughlin, Hatem H Salem, Alex S Gallus, Paul L Harper and Erica M WoodWarfarin reversal: consensus guidelines, on behalf of the Australasian Society of Thrombosis and Haemostasis Med J Aust 2004; 181 (9): 492-497.
There is also this local policy document.
With respect to the multi-trauma patient with morbid obesity:
a) Outline how the pattern of traumatic injury differs in the morbidly obese from patients with normal body habitus.
b) List the additional factors, occurring as a consequence of the patient's obesity, that need to be considered during the initial assessment.
c) List the pros and cons of focussed assessment with sonography in trauma (FAST) in the assessment of the obese multi-trauma patient.
a)
Lower injury severity scores overall.
More severe extremity injuries.
More thoracic injury.
Less brain injury – controversial.
Longer extraction time may make for higher risk for crush injury.
b)
Airway
Increased risk of partial airway obstruction when lying flat.
Possibility of difficult intubation and difficult bag mask ventilation (cervical collar, neutral position, pre-existing signs of airway obstruction, possible sleep apnoea syndrome).
Breathing
Increased difficulty inserting chest drains.
Possible obesity hypoventilation syndrome.
Increased risk of atelectasis.
Circulation
Need for appropriately sized BP cuff.
IV access more difficult so consider early inter-osseous access.
Other
Caution with analgesia.
Clinical signs, e.g. pneumothorax, difficult to detect by palpation and auscultation.
Log rolling requires additional assistants.
c)
Bedside investigation avoids transfer to CT scanner.
Technically challenging with difficulty achieving adequate beam penetration and image quality.
FAST is less sensitive than in non-obese.
False positive pericardial collections are more common in the obese.
Change in the pattern of injuries associated with morbid obesity
Influence of morbid obesity on the primary and secondary survey
Influence of morbid obesity of FAST assessment
Bochicchio, Grant V., et al. "Impact of obesity in the critically ill trauma patient: a prospective study." Journal of the American College of Surgeons 203.4 (2006): 533-538.
Diaz Jr, Jose J., et al. "Morbid obesity is not a risk factor for mortality in critically ill trauma patients." Journal of Trauma and Acute Care Surgery 66.1 (2009): 226-231.
Lambert, David M., Simon Marceau, and R. Armour Forse. "Intra-abdominal pressure in the morbidly obese." Obesity surgery 15.9 (2005): 1225-1232.
Boulanger, Bernard R., et al. "Body habitus as a predictor of injury pattern after blunt trauma." Journal of Trauma and Acute Care Surgery 33.2 (1992): 228-232.
Dhungel, Vinayak, et al. "Obesity delays functional recovery in trauma patients." journal of surgical research 193.1 (2015): 415-420.
Ciesla, David J., et al. "Obesity increases risk of organ failure after severe trauma." Journal of the American College of Surgeons 203.4 (2006): 539-545.
Arbabi, Saman, et al. "The cushion effect." Journal of Trauma and Acute Care Surgery 54.6 (2003): 1090-1093.
Evans, David C., et al. "Obesity in trauma patients: correlations of body mass index with outcomes, injury patterns, and complications." The American surgeon 77.8 (2011): 1003-1008.
Fuchs, I., et al. "Vascular Injury in Obese Patients after Ultra-Low-Velocity Trauma." J Anesth Clin Res 5.488 (2014): 2.
With respect to the management of a multi-trauma patient requiring mechanical ventilation:
Describe the injuries that require specific positioning or immobilisation of the patient and the strategies used in this context.
Include in your answer how these strategies impact upon the care of the patient.
Patients with "unstable" injuries may be at risk of secondary injury if passive or active movements are not limited.
Brain- Traumatic Brain Injury:
Head up (venous drainage)
May be at odds with spinal precautions
Priority given to greatest identified injury
Can nurse flat in bed, with entire bed angled head up
Avoid venous obstruction if TBI (collar and jugular CVC)
C-Spine injury
Collar (which type not esp evidence based- Philadelphia/Aspen/hard collar)
Particular attention to head hold in movement including airway manipulation
Lie flat (but can tilt bed if head elevation dictated by underlying TBI)
Log roll acceptable but recommended to use 4 people
Can side lie with wedge to minimise pressure injury
Should aim to remove collar as early as possible, and many trauma hospitals institute a Radiological clearance protocol using CT or MRI.
If injury is identified then collar should not be removed until definitive treatment is defined (fixation/hard collar/conservative mx)
Prolonged collar placement may lead to pressure injuries
C-spine collar may make airway access more difficult
Thoraco-lumbar spine injury
Lie flat (no bending) or side lie with a wedge.
Log roll (4 person).
Radiologic clearance protocols used commonly.
Pelvic fractures
Haemodynamic instability may be related to pelvic injury
Mechanically unstable pelvic fractures may be worsened by rolling/side lie/ sitting
Pelvic binders may be required if haemodynamically unstable
Additional fixation once injury identified- or removed if not.
Long bone fractures
No universal position restrictions
In event of clinical suspicion long bones should be immobilised to prevent embolic and haemorrhagic complications and pain
Other points
Competing injuries- precautions should relate to the most serious identified injury - e.g. a cleared spine may mean a patient can be sat up, but not in the setting of a co-existing mechanically unstable pelvis.
Likewise:
Management of ICP in TBI takes precedence over use of cervical collars.
Chest injuries/hypoxia takes precedence over spinal precautions
Intubation and securing the airway takes precedence over cervical collars/head holds
Urgency exists in identifying injuries at the earliest possible time (secondary and tertiary survey) in order to remove or increase position restrictions for the individual patient.
Emphasis should be on own practice, no single "right way" but sensible risk/benefit based approach including clinical and radiologic findings to guide practice.
Examiners' comments: Candidates who did not pass this question did not think broadly and gave a limited answer and did not adequately address the issue of competing injuries and risk v benefit.
Positioning for head injury
Positioning for C-spine injury
Positioning for T/L spine injuries
Positioning for severe chest injuries
Positioning in pelvic fractures
Positioning in long bone fractures
Positioning for the pregnant trauma patient
Competing interest
Christie, Robert James. "Therapeutic positioning of the multiply-injured trauma patient in ICU." British Journal of Nursing 17.10 (2008): 638-642.
A 19-year-old female has been admitted to your ICU 12 hours after an isolated severe traumatic brain injury. She is intubated and mechanically ventilated with FiO2 = 0.3. Complete radiological imaging and clinical examination does not demonstrate any other injuries.
You have been called to review her as she is persistently hypotensive and has not responded to fluid therapy or vasopressor treatment. She is currently receiving 30 μg/min of noradrenaline and 15 μg/min of adrenaline.
Her vital signs are:
Two images from the CT scan (CT scan A and B) of her head are shown.
(only one CT is supplied in this version of the question; it is not the original image from the paper)
What is the cause of her hypotension and how would you treat it?
Secondary adrenal insufficiency secondary to pituitary injury. Treatment is with IV hydrocortisone.
The image above was once a normal CT brain. You would not believe the difficulty of finding a CT with a sella turcica fracture via Google Images. Thus, a normal CT brain image was acquired, and a sella turcica fracture was photoshopped into it. Trainees should be aware that this is a poor second to an actual CT image, and that the college tend to use real CT images. The original was omitted from the publicly available paper, presumably because the college plans to reuse it.
Anyway: pituitary trauma.
And it is not always associated with grossly obvious sella turcica trauma.
The question is a short one, and as such does not merit an indepth answer (see the college model).
If one were interested in more detail about secondary adrenal insufficiency due to pituitary trauma, one could read this 2005 article from Critical care medicine.
Adrenal insufficiency in general is explored in greater depth elsewhere.
Kusanagi, Hiroaki, Kazunari Kogure, and Akira Teramoto. "Pituitary insufficiency after penetrating injury to the sella turcica." Journal of Nippon Medical School 67.2 (2000): 130-133.
Feiz-Erfan, Iman, et al. "Incidence and pattern of direct blunt neurovascular injury associated with trauma to the skull base." (2007). J. Neurosurg. / Volume 107 / August, 2007
Kelly, Daniel F., et al. "Hypopituitarism following traumatic brain injury and aneurysmal subarachnoid hemorrhage: a preliminary report." Journal of neurosurgery 93.5 (2000): 743-752.
Tanriverdi, Fatih, et al. "High risk of hypopituitarism after traumatic brain injury: a prospective investigation of anterior pituitary function in the acute phase and 12 months after trauma." The Journal of Clinical Endocrinology & Metabolism91.6 (2006): 2105-2111.
Benvenga, Salvatore, et al. "Hypopituitarism secondary to head trauma." The Journal of Clinical Endocrinology & Metabolism 85.4 (2000): 1353-1361.
Cohan, Pejman, et al. "Acute secondary adrenal insufficiency after traumatic brain injury: A prospective study*." Critical care medicine 33.10 (2005): 2358-2366.
A 54-year-old previously healthy male was admitted to the ICU after 45% total body surface area burns. He was pulled out of his garden shed, unconscious, by the fire brigade and was intubated at the scene of the incident by ambulance personnel. He was admitted to the ICU within one hour of injury.
a) Describe your initial fluid resuscitation plan for this patient, including the type of fluid, the rationale for your choice and how you would estimate the fluid requirements.
Three hours later, the patient remains hemodynamically unstable:
Heart rate 125 beats per minute
Blood pressure 85/45 mmHg (on noradrenaline 30 μg/min and vasopressin 0.04 units/min)
b) What are the diagnostic possibilities?
a)
Type of fluid:
Fluid resuscitation of patient with moderate to severe burns consists of an isotonic crystalloid
solution, such as Hartmann’s solution or plasmalyte. Large volumes of 0.9% NaCl may be
associated with hyperchloremic metabolic acidosis.
The colloids (albumin) are more expensive, and do not improve survival, compared to
crystalloids.
The use of hypertonic saline does not provide better outcomes than isotonic saline.
Estimating fluid requirements:
No formula provides a precise method for determining the burn victim's fluid requirements; the
formulas described provide only a starting point and guide to initial fluid resuscitation. Patient
age, severity of burns and co-morbidities can substantially alter the actual fluid requirements
of individual patients. Patient response to fluid therapy needs careful monitoring and
adjustment as clinically indicated
Parkland (or Baxter or consensus) Formula (most widely used):
Fluid requirement (ml) = 4 x body weight x percentage of burns. (Only deep)
One half of the calculated fluid is given over the first eight hours and the remaining over the
next 16 hours.
The rate of infusion should be as constant as possible; sharp decrease in infusion rates can
cause vascular collapse and increase in edema.
Modified Brooke Formula:
Fluid requirement (ml) over the initial 24 hours = 2 x body weight x percentage of burns.
This formula may reduce the total volume used in fluid resuscitation without causing harm.
Following initial resuscitation, IV fluids are administered to meet baseline fluid needs and
maintain urine output.
Care should be taken to avoid fluid overload, as associated with multiple co-morbidities.
b)
Unidentified blood loss / inadequate fluid resuscitation
Distributive shock with large fluid shifts
Cyanide toxicity
Compartment Syndrome, including abdominal compartment
Cardiogenic Shock (severe myocardial suppression caused by burns)
Carbon monoxide poisoning
Ingestion of toxins (ethylene glycol, methanol, salicylates)
Additional Examiners’ Comments:
Candidates omitted discussion on rationale for choice of fluid
A detailed dissection of fluid resuscitation for the burns patient is performed in the Required Reading section. Physiologic consequences of burns is also covered there.
In brief:
Fluid resuscitation end point:
Choice of fluids:
Resuscitation formulae
Formula | First 24 hours | Next 24 hours | ||
Choice of fluid | Volume | Choice of fluid | Volume | |
Parkland | Ringer's Lactate | 4ml/kg/% first half in 8 hrs second half in 16 hr |
Colloids only. No more crystalloids. |
20–60% of calculated plasma volume. |
Modified Parkland | Ringer's Lactate | 4ml/kg/% first half in 8 hrs second half in 16 hr |
5% albumin | 0.3–1 ml/kg/% burn/16 per hour |
Brooke | Ringer's Lactate | 1.5 ml/kg/% | Ringer's Lactate | 1.5 ml/kg/% |
Colloids | 0.5 ml/kg/% | Colloids | 0.25 ml/kg/% | |
Dextrose 5% | 2000ml | Dextrose 5% | 2000ml | |
Modified Brooke | Ringer's Lactate | 2 ml/kg/% | Colloids | 0.3–0.5 ml/kg/% |
Evans | Crystalloid | 1 ml/kg/% | Crystalloid | 0.5 ml/kg/% burn |
Colloid | 1 ml/kg/% | Colloid | 0.5 ml/kg/% burn | |
Dextrose 5% | 2000ml | |||
Monafo | 250 mEq Na 150 mEq lactate 100 mEq Cl. |
titrate to u/o | 250 mEq Na 150 mEq lactate 100 mEq Cl. |
titrate to u/o |
1/3 saline | titrate to u/o |
It is probably worth adding that this patient is at high risk of inhalational injury. He was unconscious, and sharing a small enclosed space with his fire. Naver et al (1985) demonstrated that patients with smoke inhalation injury and airway burns require a larger volume of fluid resuscitation. The total volume is increased up to 35% - 65%.
Causes of shock in the unconscious burns patient:
Let this be an exercise in generating differentials.
In more detail:
Type of shock | Cause | Diagnostic strategy | Management |
Artifact of measurement | Arterial blood pressure measurement is inaccurate | Compare with non-invasive measurement and physical examination |
|
Cardiogenic | Cytokine-induced myocardial dysfunction Alternatively, cardiac dysfunction can be associated with cyanide and carbon monoxide toxicity |
TTE, ECG, cardiac output measurement by PiCCO or PA catheter |
|
Myocardial infarction | TTE, ECG, cardiac enzymes |
|
|
Obstructive | Abdominal compartment syndrome | Measure the intra-abdominal pressure; calculate total fluid resuscitation (it is associated with over-resuscitation) |
|
Massive pulmonary embolism (unlikely - too early - more likely in the chronic recovery from burns) |
TTE, CVP trace, ECG, CTPA |
|
|
Tension pneumothorax (likely, if there the patient was in some sort of explosion) |
Physical examination; CXR |
|
|
Neurogenic | Spinal injury due to fall; may have gone unrecognised given that the patient was found unconscious | Physical examination features, CT, MRI |
|
Hypovolemic | Blood loss | Examination of the patient, FBC, DIC screen |
|
Under-resuscitated burns shock | Compare fluid resuscitation with predicted expectations as based on the formulae |
|
|
Distributive | Vasoplegia due to SIRS | SVRI measurements by PiCCO |
|
Anaphylaxis | Physical examination findings suggestive of angioedema |
|
|
Cytotoxic | Cyanide toxicity due to smoke inhalation | Lactate levels; cyanide levels |
|
Mitra, Biswadev, et al. "Fluid resuscitation in major burns." ANZ journal of Surgery 76.1‐2 (2006): 35-38.
Haberal, Mehmet, A. Ebru Sakallioglu Abali, and Hamdi Karakayali. "Fluid management in major burn injuries." Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India 43.Suppl (2010): S29.
Fodor, Lucian, et al. "Controversies in fluid resuscitation for burn management: Literature review and our experience." Injury 37.5 (2006): 374-379.
Bak, Zoltan, et al. "Hemodynamic changes during resuscitation after burns using the Parkland formula." Journal of Trauma and Acute Care Surgery 66.2 (2009): 329-336.
Blumetti, Jennifer, et al. "The Parkland formula under fire: is the criticism justified?." Journal of burn care & research 29.1 (2008): 180-186.
Baxter, Charles R., and Tom Shires. "Physiological response to crystalloid resuscitation of severe burns." Annals of the New York Academy of Sciences 150.3 (1968): 874-894.
Saffle, Jeffrey R. "The phenomenon of “fluid creep” in acute burn resuscitation." Journal of burn care & research 28.3 (2007): 382-395.
Naver, P. D., J. R. Saffle, and G. D. Warden. "Effect of inhalation injury on fluid resuscitation requirements after thermal injury." Plastic and Reconstructive Surgery 78.4 (1986): 550.
Arlati, S., et al. "Decreased fluid volume to reduce organ damage: a new approach to burn shock resuscitation? A preliminary study." Resuscitation 72.3 (2007): 371-378.
Bittner, Edward A., et al. "Acute and Perioperative Care of the Burn-Injured Patient." Survey of Anesthesiology 59.3 (2015): 117.
Melinyshyn, Alex, et al. "Albumin supplementation for hypoalbuminemia following burns: unnecessary and costly!." Journal of Burn Care & Research 34.1 (2013): 8-17.
Cooper, Andrew B., et al. "Five percent albumin for adult burn shock resuscitation: lack of effect on daily multiple organ dysfunction score." Transfusion 46.1 (2006): 80-89.
Wilkes, NICHOLAS J. "Hartmann's solution and Ringer's lactate: targeting the fourth space." Clinical Science 104.1 (2003): 25-26.
MONAFO, WILLIAM W. "The treatment of burn shock by the intravenous and oral administration of hypertonic lactated saline solution." Journal of Trauma and Acute Care Surgery 10.7 (1970): 575-586.
Huang, Peter P., et al. "Hypertonic sodium resuscitation is associated with renal failure and death." Annals of surgery 221.5 (1995): 543.
Sun, Ye-Xiang, et al. "Effect of 200 mEq/L Na+ hypertonic saline resuscitation on systemic inflammatory response and oxidative stress in severely burned rats." Journal of Surgical Research 185.2 (2013): 477-484.
Paratz, Jennifer D., et al. "Burn Resuscitation—Hourly Urine Output Versus Alternative Endpoints: A Systematic Review." Shock 42.4 (2014): 295-306.
Walker, Steven C., et al. "Balanced Electrolyte Solution Reduces Acidosis as Compared to Normal Saline in the Resuscitation of Perioperative Burn Patients." Anesthesiology 95 (2001): A375.
A 42-year-old primigravida, 30 weeks gestation, is admitted with abdominal trauma and hypotension, following a motor vehicle crash, to the Emergency Department of a hospital without an obstetric service.
Outline the management issues specific to the care of this patient.
In addition to management by a trauma team following EMST principles, this case requires additional early obstetric, neonatal and anaesthetic input. The operating theatre needs to be alerted to the possibility of the need for emergency Caesarian section. In an elderly primigravida this is likely to be a ‘precious’ pregnancy.
Other specific management issues include:
Additional comments:
Some candidates wrote about trauma management in general and/or did not address the issues of abdominal trauma and hypotension in a pregnant patient.
In summary:
Issues to consider in investigations and the secondary survey
Oh's Intensive Care manual: Chapter 64 (pp. 684) General obstetric emergencies by Winnie TP Wan and Tony Gin
Soar, Jasmeet, et al. "European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution." Resuscitation 81.10 (2010): 1400-1433.
Mattox, Kenneth L., and Laura Goetzl. "Trauma in pregnancy." Critical care medicine 33.10 (2005): S385-S389.
DROST, THOMAS F., et al. "Major trauma in pregnant women: maternal/fetal outcome." Journal of Trauma-Injury, Infection, and Critical Care 30.5 (1990): 574-578.
With respect to heat stroke:
a) Outline the pathophysiology. (20% marks)
b) List the factors that affect prognosis. (10% marks)
c) List the expected changes on routine investigations in the presence of heat stroke. (20% marks)
d) Outline the management of a patient with heat stroke. (50% marks)
a)
Uncoupling of oxidative phosphorylation
Failure of enzyme systems
Membrane permeability
increased Na leak into cells
ADP depleted
Sweat gland damage from heat
b)
Prognosis depends on core temp, duration of hyperthermia and presence of comorbidities.
c)
Haemoconcentration (dehydration), haemolysis
Hypernatremia
LFT derangements (cholestatic, early sign),
Renal impairment,
DIC often delayed onset and a/w worse prognosis
CK rise (exertional type),
Lactate rise.
During treatment: CXR pulmonary oedema (centralise fluid, ALI), low PO4, Ca, glucose,
d)
ABC (Airway protection if GCS low etc. ) & control of seizures if present
Remove from offending environment,
Rapid cooling to 39 C (duration of hyperthermia major determinant of outcome): remove clothing, sponge cold water, ice, fans, cooling blankets, cold intravenous fluids gastic lavage with cold solutions, immersion (young and military), cold dialysis, etc. Monitor core temp closely
Volume and electrolyte resuscitation and close monitoring
ABG,
Eectrolytes. NB Risk of cerebral oedema
CVC
Additional comments:
In general there was a knowledge deficit relating to the pathophysiology of heat stroke. Some candidates failed to address cooling and control of temperature in the management of heat stroke and did not recognise the need for initial rapid cooling and/ or the need for careful temperature monitoring.
The
a) Pathophysiology of heat stroke:
b) Factors that affect prognosis of heat stroke:
c) List the expected changes on routine investigations in the presence of heat stroke.
d) Outline the management of a patient with heat stroke.
Bouchama, Abderrezak, and James P. Knochel. "Heat stroke." New England Journal of Medicine 346.25 (2002): 1978-1988.
Grogan, H., and P. M. Hopkins. "Heat stroke: implications for critical care and anaesthesia." British Journal of Anaesthesia 88.5 (2002): 700-707.
Glazer, James L. "Management of heatstroke and heat exhaustion." Am Fam Physician 71.11 (2005): 2133-2140.
Bricknell, M. C. "Heat illness--a review of military experience (Part 1)." Journal of the Royal Army Medical Corps 141.3 (1995): 157-166.
Bricknell, M. C. M. "Heat illness-A review of military experience (Part 2)." Journal of the Royal Army Medical Corps 142.1 (1996): 34-42.
Leon, Lisa R., and Bryan G. Helwig. "Heat stroke: role of the systemic inflammatory response." Journal of applied physiology 109.6 (2010): 1980-1988.
Alzeer, Abdulaziz H., et al. "Serum enzymes in heat stroke: prognostic implication." Clinical chemistry 43.7 (1997): 1182-1187.
Bouchama, Abderrezak, Mohammed Dehbi, and Enrique Chaves-Carballo. "Cooling and hemodynamic management in heatstroke: practical recommendations." Crit Care 11.3 (2007): R54.
Misset, Benoît, et al. "Mortality of patients with heatstroke admitted to intensive care units during the 2003 heat wave in France: A national multiple-center risk-factor study*." Critical care medicine 34.4 (2006): 1087-1092.
You have been called to the Emergency Room to review a previously well adult male who has sustained a penetrating injury to the root of the neck.
a) Describe the anatomy of the root of the neck on the left side describing the clinically important
structures that may be injured. (50% marks)
b) Outline the issues specific to management of a penetrating neck injury. (50% marks)
a)
The root of the neck is the junction between the thorax and the neck. It opens into, and is the cervical side of, the superior thoracic aperture, through which pass all structures going from the head to the thorax and vice versa. The root of the neck is bound laterally by the first rib, anteriorly by the manubrium, and posteriorly by the T1 vertebrae.
From anterior to posterior, the major contents are:
Subclavian artery and branches
Subclavian vein and tributaries (EJV)
Trachea
Oesopahagus
Vagus nerve
Recurrent Laryngeal nerve
Dome of pleura
Brachial plexus
Lymphatics and thoracic duct
Phrenic nerve
Sympathetic chain, stellate ganglion
Scalene muscle.
Clavicle
b)
Requires management at a trauma centre with appropriate expertise. May require multiple speciality input - interventional radiology, ENT, vascular, cardiothoracic.
Airway issues:
Urgent surgical exploration required for haemodynamic compromise, expanding or pulsatile haematoma, extensive subcutaneous emphysema, stridor, or neurological deficit with intra op bronchoscopy/ endoscopy/ angiography if available.
If no indication for urgent surgical exploration requires CT angiography (or equivalent) with close
observation in ICU +/- flexible laryngoscopy +/- endoscopy +/- oral contrast swallow study.
Additional Examiners’ Comments:
Most candidates were not aware of the issues and management priorities associated with this type of trauma.
Anatomy is not our strong suite. This question describes injury to Zone 1 of the neck, where all the important stuff seems to be. For an excellent revision of the important issues, the interested trainees are directed to Karim Brohi's 2002 write-up of neck wounds on trauma.org.
Generic approach to management:
Specific concerns in a Zone 1 injury:
Reasons for urgent surgical exploration:
You have been asked to assess a previously healthy 32-year-male who has presented following a high-speed motorbike accident.
He has a Glasgow Coma Score of 15, a distended abdomen and a bleeding left leg wound. His current vital signs are as follows:
The trauma surgeon plans to perform exploratory laparotomy and open reduction and fixation of a left proximal femur fracture.
The results of blood parameters are as follows:
Parameter |
Patient Value |
Normal Adult Range |
|||
Haemoglobin |
61 g/L* |
115 – 160 |
|||
White Cell Count |
13.2 x 109/L* |
4.0 – 11.0 |
|||
Platelets |
46 x 109/L* |
150 – 400 |
|||
International Normalised Ratio (INR) |
1.9* |
0.8 – 1.2 |
|||
Activated Partial Thromboplastin Time (APTT) |
43 seconds* |
22 – 27 |
|||
Fibrinogen |
1.1 g/L* |
2.0 – 4.0 |
Arterial Blood Gas values are:
Parameter |
Patient Value |
Normal Adult Range |
|||||||
FiO2 |
0.21 |
||||||||
pH |
7.29* |
7.35 – 7.45 |
|||||||
pCO2 |
25 mmHg* (3.3 kPa)* |
35 – 45 (4.6 – 6.0) |
|||||||
PaO2 |
80 mmHg (10.5 kPa) |
||||||||
HCO3 |
12 mmol/L* |
22 – 27 |
|||||||
Lactate |
3.7 mg/L* |
< 1.5 |
|||||||
Base Excess |
-11 mmol/L* |
-2 – +2 |
a) Describe your strategies to control the bleeding in this patient. (70% marks)
b) What evidence is there for the use of tranexamic acid in this setting? (30% marks)
Medical Measures to control bleeding
Activate Massive Transfusion Protocol as per local hospital guidelines. Close liaison with surgeon and haematologist is warranted.
Local pressure including adjunctive tourniquet use to control bleeding from the left leg wound.
Target lower systolic blood pressure (e.g. 80 mmHg) until major bleeding has been stopped (absence of brain injury permits the same). Permissive hypotension is tolerated and has shown survival benefits in some studies.
Correct hypothermia and acidosis.
Packed cells transfusion to target haemoglobin concentration 70 – 90 g/L to achieve adequate tissue perfusion.
Fresh Frozen Plasma to maintain INR & APTT < 1.5 x mean control. Usual dose 15 mL/kg.
Cryoprecipitate to maintain Fibrinogen levels > 1.5 g/L. Usual dose is 3-4 g or 50 mg/kg. (Fibrinogen
concentrate is also allowed).
Platelet transfusion to keep platelets > 50 x 109/L. With multiple injuries and suspicion of micro-vascular bleeding; platelet count can be aimed at > 100 x 109/L.
Supplemental Calcium to maintain ionised calcium > 1.1 mmol/L
Fluid Resuscitation with warmed crystalloid solutions. Aggressive fluid resuscitation is no longer recommended due to risk of pulmonary oedema, worsening of thrombocytopenia and coagulopathy due to haemoduilution.
Use of ROTEM/TEG targets Tranexamic Acid (see below)
Recombinant Factor VIIa: Not indicated at this stage (prior to surgery).
b)
Tranexamic Acid (TXA) is a synthetic lysine analogue that is a competitive inhibitor of plasminogen. TXA is distributed throughout all tissues with plasma half-life of 120 minutes.
Evidence: Recently published CRASH 2 trial; a multi-centre randomised, controlled trial examined the role of TXA against placebo in trauma patients, with, or at risk of significant haemorrhage. In more than 20,000 patients; TXA demonstrated a significant reduction in all-cause mortality at 4 weeks after injury (14.5% vs. 16%; RR = 0.91, P = 0.0035) and risk of death from bleeding (4.9% vs. 5.7%; RR=0.85, p=0.00077).
The risk of precipitated thrombosis with the use of the lysine analogues has been of major theoretical concern; however, CRASH-2 showed that the rate of thrombosis, especially myocardial infarction, was lower with the use of TXA. No adverse events were described with the use of TXA in CRASH-2, although an increased rate of seizures has been described in patients receiving a high dose of TXA when undergoing cardiac surgery.
A further analysis of CRASH-2 data showed that early treatment (< 1 hour and 1-3 hour from injury) significantly reduced the death rate of bleeding but treatment administered after 3 hours; increased the risk of death due to bleeding. Hence, TXA should be administered within 3 hours of injury.
TXA should be considered as adjunctive therapy in patients with traumatic haemorrhage in the setting of overall patient management; including strict attention to the control of bleeding, physiological and metabolic parameters, coagulation and temperature maintenance.
Additional Examiners’ Comments:
Most candidates answered this question well although knowledge relating to the evidence for tranexamic acid was overall limited. Some gave a reasonable discussion of the medical management of bleeding but omitted surgical strategies.
The mess we're in:
Immediate resuscitation:
Within the first 6 hours:
Endpoint goals within the first 6 hours:
Evidence for the use of tranexamic acid in trauma
Criticism of this evidence
Sankarankutty, Ajith, et al. "TEG® and ROTEM® in trauma: similar test but different results." World J Emerg Surg 7.Suppl 1 (2012): S3.
Shoemaker, William C. "Comparison of the relative effectiveness of whole blood transfusions and various types of fluid therapy in resuscitation." Critical care medicine 4.2 (1976): 71-78.
El Sayad, Mohamed, and Hussein Noureddine. "Recent Advances of Hemorrhage Management in Severe Trauma." Emergency medicine international 2014 (2014).
Castellucci, Lana Antoinette. Evaluating Risk of Delayed Major Bleeding in Critically Ill Trauma Patients. Diss. University of Ottawa, 2016.
Stensballe, Jakob, and John B. Holcomb. "Hemostatic resuscitation is neither hemostatic nor resuscitative in trauma hemorrhage—But did they in fact test the effect of hemostatic resuscitation?." Journal of Trauma and Acute Care Surgery 78.6 (2015): 1237.
MacLeod, Jana BA, et al. "Early coagulopathy predicts mortality in trauma." Journal of Trauma and Acute Care Surgery 55.1 (2003): 39-44.
Lier, Heiko, et al. "Preconditions of hemostasis in trauma: a review. The influence of acidosis, hypocalcemia, anemia, and hypothermia on functional hemostasis in trauma." Journal of Trauma and Acute Care Surgery 65.4 (2008): 951-960.
With regards to high-voltage electrical injuries:
a) List the factors determining the severity of electrical burn injuries. (30% Marks)
b) List the potential causes of poor lung compliance in a patient who is receiving invasive mechanical ventilation post high-voltage electrical injury. (40% Marks)
c) A patient who has suffered a high-voltage electrical injury is noted on day 2 to have dark coloured urine and a creatine kinase (CK) that is elevated at 32 000 U/L. How will you manage this clinical problem?
(30% marks)
a)
b)
c)
a)
Factors determining the severity of electrical injuries in general (Kombourlis et al, 2002)
Factors determining the severity of electrical burns specifically:
b)
" List the potential causes of poor lung compliance", they asked. This is weird, because according to Koumbourlis, "there are no specific injuries to the lungs or the airways directly attributable to electric current." In view of this, the author was forced to concoct an imaginative list of respiratory complications for a condition which usually has none.
c)
Something specific to high voltage electrical injury is the need to debride the necrotic muscle. Occasionally, the whole limb is unviable and must be amputated.
As far as generic mangement of rhabdomyolysis, a recent meta-analysis of management strategies has presented the following conclusions:
Bernstein, Theodore. "Electrical injury: electrical engineer's perspective and an historical review." Annals of the New York Academy of Sciences 720.1 (1994): 1-10.
Koumbourlis, Anastassios C. "Electrical injuries." Critical care medicine 30.11 (2002): S424-S430.
Kisner, Suzanne, and Virgil Casini. "Epidemiology of electrocution fatalities." (2002).
PITTS, WILLIAM, et al. "Electrical burns of lips and mouth in infants and children." Plastic and reconstructive surgery 44.5 (1969): 471-479.
Rosen, Carlo L., et al. "Early predictors of myoglobinuria and acute renal failure following electrical injury." The Journal of emergency medicine 17.5 (1999): 783-789.
Brumback, Roger A., Daniel L. Feeback, and Richard W. Leech. "Rhabdomyolysis following electrical injury." Seminars in neurology. Vol. 15. No. 04. © 1995 by Thieme Medical Publishers, Inc., 1995.
Price, Timothy G., and Mary Ann Cooper. "Electrical and lightning injuries." Marx et al. Rosen’s Emergency Medicine, Concepts and Clinical Practice, Mosby, 22 (2006): 67-78.
With respect to the trauma patient:
a) List the key clinical signs of traumatic asphyxia. (30% Marks)
b) Explain the term resuscitative thoracotomy. Give the indications for and contra-indications to resuscitative thoracotomy in patients with acute chest trauma. (70% Marks)
a)
The key clinical signs to indicate a patient has sustained traumatic asphyxiation include:
b)
Resuscitative thoracotomy is a procedure of last resort that is nearly always performed in the emergency department and involves gaining rapid access to the heart and major thoracic vessels through an anterolateral chest incision or clam shell incision to control exsanguinating haemorrhage or other life-threatening chest injuries
What are the indications for resuscitative thoracotomy?
Accepted Indications
Relative Indications
Contraindications to resuscitative thoracotomy
This SAQ was not passed by anybody, which again brings into question the utility of asking trainees about such esoterica as traumatic asphyxia or pyroglutamic acidosis. Does one's inability to discuss these topics really act as a sensitive discriminator to tell "junior consultant" from "competent senior registrar"?
Anyway.
a) "Traumatic asphyxia" is defined as "a form of suffocation where respiration is prevented by external pressure on the body". It is essentially a crush injury of the thorax, with impaired respiration as the result of greatly decreased chest expansion. Failure of venous return from the upper body results in the characteristic clinical findings, all of which can be attributed to greatly increased venous pressure. This list of signs is composed on the basis of articles by Byard et al (2006) and Eken et al (2009)
Common features:
Uncommon features:
Other sequelae:
b) Resuscitative thoracotomy is defined as a left-sided clamshell thoracotomy performed for the specific purpose of gaining rapid access to the heart and major thoracic vessels.
Indications for resuscitative thoracotomy (Rabinowici et al, 2014)
Contraindications for resuscitative thoracotomy
Morrison, Jonathan J., et al. "Resuscitative thoracotomy following wartime injury." Journal of Trauma and Acute Care Surgery 74.3 (2013): 825-829.
Burlew, Clay Cothren, et al. "Western Trauma Association critical decisions in trauma: resuscitative thoracotomy." Journal of Trauma and Acute Care Surgery 73.6 (2012): 1359-1363.
Ohrt-Nissen, S., et al. "Indication for resuscitative thoracotomy in thoracic injuries—Adherence to the ATLS guidelines. A forensic autopsy based evaluation." Injury 47.5 (2016): 1019-1024.
Rabinovici, Reuven, and N. Bugaev. "Resuscitative thoracotomy: an update." Scandinavian Journal of Surgery (2014): 1457496913514735.
CALS program manual: "Emergency Thoracotomy (Circulation Skills 4)"
Working Group, Ad Hoc Subcommittee on Outcomes. "Practice management guidelines for emergency department thoracotomy." Journal of the American College of Surgeons 193.3 (2001): 303-309.
Keller, Deborah, et al. "Life after near death: long-term outcomes of emergency department thoracotomy survivors." Journal of Trauma and Acute Care Surgery 74.5 (2013): 1315-1320.
Eken, Cenker, and Ozlem Yıgıt. "Traumatic asphyxia: a rare syndrome in trauma patients." International journal of emergency medicine 2.4 (2009): 255-256.
Williams, James S., Stanely L. Minken, and James T. Adams. "Traumatic asphyxia--reappraised." Annals of surgery 167.3 (1968): 384.
Byard, Roger W., et al. "The pathological features and circumstances of death of lethal crush/traumatic asphyxia in adults—a 25-year study." Forensic science international 159.2 (2006): 200-205.
Miyaishi, S., et al. "Negligent homicide by traumatic asphyxia." International journal of legal medicine 118.2 (2004): 106-110.
Byard, Roger W. "The brassiere ‘sign’–a distinctive marker in crush asphyxia." Journal of clinical forensic medicine 12.6 (2005): 316-319.
Dwek, J. "Ecchymotic mask." The Journal of the International College of Surgeons 9 (1946): 257.
Choi, Young Joo, et al. "Bilateral retrobulbar hemorrhage and visual loss following traumatic asphyxia." Korean journal of ophthalmology 24.6 (2010): 380-383.
Richards, Claire E., and Daniel N. Wallis. "Asphyxiation: a review." Trauma 7.1 (2005): 37-45.
A 54-year-old previously healthy male was admitted to the ICU within one hour after sustaining burns to 45% total body surface area. He had been pulled out of his garden shed, unconscious, by the fire brigade and intubated at the scene of the incident by the paramedics.
a) Describe your initial fluid resuscitation plan for this patient including type of fluid, rationale for your choice and estimation of the fluid requirements. (60% marks)
Three hours after presentation, despite adequate fluid resuscitation, the patient remains haemodynamically unstable.
Heart rate 125 beats/min
Blood pressure 85/45 mmHg (on noradrenaline 30 mcg/min and vasopressin 0.04 units/min)
Arterial blood gas result is as follows:
Parameter |
Patient Value |
Normal Adult Range |
Fi02 |
0.5 |
|
pH |
7.21* |
7.35 - 7.45 |
PC02 |
22 mmHq (2.9 kPa)* |
35 - 45 (4.6 - 6.0) |
P02 |
90 mmHq (11.8 kPa) |
|
Bicarbonate |
8 mmol/L* |
22 - 28 |
Base excess |
-15 mmol/L* |
-2 - +2 |
b) List the possible causes for this clinical picture. (40% marks)
a) Type of fluid:
Fluid resuscitation of patient with moderate to severe burns consists of an isotonic crystalloid solution, such as Hartmann‟s solution or plasmalyte. Large volumes of 0.9% NaCl may be associated with hyperchloremic metabolic acidosis.
The colloids (albumin) are more expensive, and do not improve survival, compared to crystalloids.
The use of hypertonic saline does not provide better outcomes than isotonic saline.
Estimating fluid requirements:
No formula provides a precise method for determining the burn victim's fluid requirements; the formulas described provide only a starting point and guide to initial fluid resuscitation. Patient age, severity of burns and co-morbidities can substantially alter the actual fluid requirements of individual patients.
Parkland (or Baxter or consensus) Formula (most widely used):
Fluid requirement (ml) = 4 x body weight x percentage of burns. (Only deep)
One half of the calculated fluid is given over the first eight hours and the remaining over the next 16 hours.
The rate of infusion should be as constant as possible; sharp decrease in infusion rates can cause vascular collapse and increase in edema.
Modified Brooke Formula: Fluid requirement (ml) over the initial 24 hours = 2 x body weight x percentage of burns.
This formula may reduce the total volume used in fluid resuscitation without causing harm.
Following initial resuscitation, IV fluids are administered to meet baseline fluid needs and maintain urine output.
Care should be taken to avoid fluid overload, as associated with pulmonary edema, peripheral edema leading to compartment syndrome.
Inadequate resuscitation suggested by poor urine output should be managed by judicious fluid boluses and an increase in the infusion rate.
b) List the diagnostic possibilities
Cardiogenic Shock (severe myocardial suppression caused by burns, pre-existing myocardial dysfunction)
Cyanide toxicity
Compartment Syndrome, including abdominal compartment
Carbon monoxide poisoning
Blast injury
Ingestion of toxins (ethylene glycol, methanol, salicylates)
Acute Liver Failure
Additional Examiners' Comments:
Most of the candidates answered this question very well. Candidates who did not pass showed knowledge gaps, poor synthesis of knowledge and poorly structured answers.
This question closely resembles Question 21 from the first paper of 2014, with the exception of the fact that this time an ABG was also offered.The ABG does not add very much to the process of answering this question, and therefore the discussion section for Question 21 is reproduced here with minimal modification.A detailed dissection of fluid resuscitation for the burns patient is performed in the Required Reading section. Physiologic consequences of burns is also covered there. The ABG looks like a metabolic acidosis, which would accompany any sort of shock state - and so the "Causes of Shock in the Acute Burns Patient" table was still relevant here.
a)
In brief:
Fluid resuscitation end point:
Choice of fluids:
Resuscitation formulae
Formula | First 24 hours | Next 24 hours | ||
Choice of fluid | Volume | Choice of fluid | Volume | |
Parkland | Ringer's Lactate | 4ml/kg/% first half in 8 hrs second half in 16 hr |
Colloids only. No more crystalloids. |
20–60% of calculated plasma volume. |
Modified Parkland | Ringer's Lactate | 4ml/kg/% first half in 8 hrs second half in 16 hr |
5% albumin | 0.3–1 ml/kg/% burn/16 per hour |
Brooke | Ringer's Lactate | 1.5 ml/kg/% | Ringer's Lactate | 1.5 ml/kg/% |
Colloids | 0.5 ml/kg/% | Colloids | 0.25 ml/kg/% | |
Dextrose 5% | 2000ml | Dextrose 5% | 2000ml | |
Modified Brooke | Ringer's Lactate | 2 ml/kg/% | Colloids | 0.3–0.5 ml/kg/% |
Evans | Crystalloid | 1 ml/kg/% | Crystalloid | 0.5 ml/kg/% burn |
Colloid | 1 ml/kg/% | Colloid | 0.5 ml/kg/% burn | |
Dextrose 5% | 2000ml | |||
Monafo | 250 mEq Na 150 mEq lactate 100 mEq Cl. |
titrate to u/o | 250 mEq Na 150 mEq lactate 100 mEq Cl. |
titrate to u/o |
1/3 saline | titrate to u/o |
It is probably worth adding that this patient is at high risk of inhalational injury. He was unconscious, and sharing a small enclosed space with his fire. Naver et al (1985) demonstrated that patients with smoke inhalation injury and airway burns require a larger volume of fluid resuscitation. The total volume is increased up to 35% - 65%.
b)
Causes of shock in the unconscious burns patient with metabolic acidosis
Let this be an exercise in generating differentials.
In more detail:
Type of shock | Cause | Diagnostic strategy | Management |
Artifact of measurement | Arterial blood pressure measurement is inaccurate | Compare with non-invasive measurement and physical examination |
|
Cardiogenic | Cytokine-induced myocardial dysfunction Alternatively, cardiac dysfunction can be associated with cyanide and carbon monoxide toxicity |
TTE, ECG, cardiac output measurement by PiCCO or PA catheter |
|
Myocardial infarction | TTE, ECG, cardiac enzymes |
|
|
Obstructive | Abdominal compartment syndrome | Measure the intra-abdominal pressure; calculate total fluid resuscitation (it is associated with over-resuscitation) |
|
Massive pulmonary embolism (unlikely - too early - more likely in the chronic recovery from burns) |
TTE, CVP trace, ECG, CTPA |
|
|
Tension pneumothorax (likely, if there the patient was in some sort of explosion) |
Physical examination; CXR |
|
|
Neurogenic | Spinal injury due to fall; may have gone unrecognised given that the patient was found unconscious | Physical examination features, CT, MRI |
|
Hypovolemic | Blood loss | Examination of the patient, FBC, DIC screen |
|
Under-resuscitated burns shock | Compare fluid resuscitation with predicted expectations as based on the formulae |
|
|
Distributive | Vasoplegia due to SIRS | SVRI measurements by PiCCO |
|
Anaphylaxis | Physical examination findings suggestive of angioedema |
|
|
Cytotoxic | Cyanide toxicity due to smoke inhalation | Lactate levels; cyanide levels |
|
Mitra, Biswadev, et al. "Fluid resuscitation in major burns." ANZ journal of Surgery 76.1‐2 (2006): 35-38.
Haberal, Mehmet, A. Ebru Sakallioglu Abali, and Hamdi Karakayali. "Fluid management in major burn injuries." Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India 43.Suppl (2010): S29.
Fodor, Lucian, et al. "Controversies in fluid resuscitation for burn management: Literature review and our experience." Injury 37.5 (2006): 374-379.
Bak, Zoltan, et al. "Hemodynamic changes during resuscitation after burns using the Parkland formula." Journal of Trauma and Acute Care Surgery 66.2 (2009): 329-336.
Blumetti, Jennifer, et al. "The Parkland formula under fire: is the criticism justified?." Journal of burn care & research 29.1 (2008): 180-186.
Baxter, Charles R., and Tom Shires. "Physiological response to crystalloid resuscitation of severe burns." Annals of the New York Academy of Sciences 150.3 (1968): 874-894.
Saffle, Jeffrey R. "The phenomenon of “fluid creep” in acute burn resuscitation." Journal of burn care & research 28.3 (2007): 382-395.
Naver, P. D., J. R. Saffle, and G. D. Warden. "Effect of inhalation injury on fluid resuscitation requirements after thermal injury." Plastic and Reconstructive Surgery 78.4 (1986): 550.
Arlati, S., et al. "Decreased fluid volume to reduce organ damage: a new approach to burn shock resuscitation? A preliminary study." Resuscitation 72.3 (2007): 371-378.
Bittner, Edward A., et al. "Acute and Perioperative Care of the Burn-Injured Patient." Survey of Anesthesiology 59.3 (2015): 117.
Melinyshyn, Alex, et al. "Albumin supplementation for hypoalbuminemia following burns: unnecessary and costly!." Journal of Burn Care & Research 34.1 (2013): 8-17.
Cooper, Andrew B., et al. "Five percent albumin for adult burn shock resuscitation: lack of effect on daily multiple organ dysfunction score." Transfusion 46.1 (2006): 80-89.
Wilkes, NICHOLAS J. "Hartmann's solution and Ringer's lactate: targeting the fourth space." Clinical Science 104.1 (2003): 25-26.
MONAFO, WILLIAM W. "The treatment of burn shock by the intravenous and oral administration of hypertonic lactated saline solution." Journal of Trauma and Acute Care Surgery 10.7 (1970): 575-586.
Huang, Peter P., et al. "Hypertonic sodium resuscitation is associated with renal failure and death." Annals of surgery 221.5 (1995): 543.
Sun, Ye-Xiang, et al. "Effect of 200 mEq/L Na+ hypertonic saline resuscitation on systemic inflammatory response and oxidative stress in severely burned rats." Journal of Surgical Research 185.2 (2013): 477-484.
Paratz, Jennifer D., et al. "Burn Resuscitation—Hourly Urine Output Versus Alternative Endpoints: A Systematic Review." Shock 42.4 (2014): 295-306.
Walker, Steven C., et al. "Balanced Electrolyte Solution Reduces Acidosis as Compared to Normal Saline in the Resuscitation of Perioperative Burn Patients." Anesthesiology 95 (2001): A375
A 65-year-old male with a past history of ischaemic heart disease is admitted to the ICU after a motorcycle crash having sustained long bone fractures of the lower limbs. He has no head, chest or abdominal injuries.
Prior to surgery, his Glasgow Coma Scale (GCS) was 15 and Sp02 was 98% on 4 L/min oxygen via a Hudson mask, and chest X-ray was normal. He required prolonged operative fixation of his fractures and that was complicated by significant blood loss. Intra-operatively, he also developed an increasing oxygen requirement.
On arrival in ICU, his most recent arterial blood gas, taken on a Fi02 of 0.7 shows Pa02 of 55 mmHg (7.3 kPa).
List the differential diagnoses for his respiratory failure. (30% marks)
Outline the steps in your assessment of this patient to help determine the diagnosis. (70% marks)
a) Differential diagnoses
b) Assessment
The possible differentials must be broad. Why?
Thus, perioperative hypoxia could have resulted from any combination of the following differentials:
To discriminate among them, the following investigative steps might be taken:
History from the anaesthetist:
Examination of the patient, looking for
Laboratory tests, looking for:
Imaging
Mellor, A., and N. Soni. "Fat embolism." Anaesthesia 56.2 (2001): 145-154.
Gurd, Alan R., and R. I. Wilson. "The fat embolism syndrome." Journal of Bone & Joint Surgery, British Volume 56.3 (1974): 408-416.
Myers, R., and J. J. Taljaard. "Blood alcohol and fat embolism syndrome." J Bone Joint Surg Am 59.7 (1977): 878-880.
Hofmann, S., G. Huemer, and M. Salzer. "Pathophysiology and management of the fat embolism syndrome." Anaesthesia 53.S2 (1998): 35-37.
You are the leader on the retrieval team for a patient with cerebral arterial gas embolism (CAGE) following a scuba diving accident to your regional Hyperbaric Centre, 300 km away. The patient is intubated, ventilated and on vasopressors.
Outline the strategies needed in preparation, planning and implementation to ensure safe transport of the patient, including the necessary strategies for the patient's specific condition.
A. General; compliance with CICM/ANZCA/ACEM guideline;
Possible clinical impact of the transport environment (in this case flight environment may be particularly deleterious if patient is exposed to sub-atmospheric pressure).
a) Team with suitable training and experience
b) Equipment- appropriate ventilator, monitors, alarms, devices for manual handling, pumps to maintain infusions. Full list from the CICM guideline not required but key elements needed
c) All drugs should be checked and clearly labelled prior to administration. The range of drugs available should include all drugs necessary to manage acute life-threatening medical emergencies and those specific to the patient’s clinical condition
d) Liaison with the receiving centre ensuring key details have been conveyed, especially relevant in this case
e) Final preparation of the patient should be made prior to transport, with anticipation of clinical needs. Examples include giving appropriate doses of muscle relaxants or sedatives, replacing near-empty inotrope and other intravenous solutions with fresh bags, and emptying drainage bags
B. Specific to condition; Need to consider mode of transport
The candidates needed to be aware that minimal cabin altitude is a key part of management.
C. Interim management in liaison with hyperbaric unit
Additional Examiners’ Comments: This answer template is long and detailed and it was not expected that candidates needed to reproduce it all to obtain a pass. Important points were the awareness and compliance with guidelines on transport of critically ill patients, and the awareness that minimising flight altitude is essential.
Preparation, planning and implementation of transfer sounds a lot like a question on aeromedical retrieval. However, for some reason this gas embolism question ended up in the Trauma category.
Administrative/logistic planning of the transfer:
Preparation of the patient
Preparation of personnel and family
ANZCA "Guidelines for Transport of Critically Ill Patients
CICM "Minimum Standards for Transport of Critically Ill Patients" (IC-10, 2010)
Warren, Jonathan, et al. "Guidelines for the inter-and intrahospital transport of critically ill patients*." Critical care medicine 32.1 (2004): 256-262.
Bennett, P. B., and R. E. Moon. "Final summary of recommendations: diving accident workshop." Diving Accident Management: Undersea and Hyperbaric Medical Society, Bethesda, MD (1990): 366-369.
Stephenson, Jeffrey C. "Pathophysiology, treatment and aeromedical retrieval of SCUBA-related DCI." Journal of Military and Veterans Health 17.3 (2009): 10.
A 37-year-old male has been admitted to your ICU following an explosion in his garage. He has suffered a mixture of partial and deep burns estimated at 35% total body surface area, and has been intubated in the Emergency Department. After one hour of resuscitation in your unit he remains hypotensive with a blood pressure of 80/50 mmHg.
List the potential causes and outline how you would diagnose and manage them.
1. Spurious
i. Increase fluid resuscitation rate
a. Review/repeat trauma imaging
i. Blood product resuscitation, correction of coagulopathy ii. Operative/Interventional radiology interventions to treat cause
i. Mixed venous oxygen, empirical antidote administration
Cardiogenic
b. Abdominal compartment syndrome
i. Bladder pressure, escharotomies, laparotomy/laparostomy
c. Tamponade
i. Echo and pericardiocentesis
Examiners comments:
Most candidates were not able to amalgamate the three crucial aspects of this patient i.e., trauma in a burns patient in the setting of a closed area explosion.
Many focused solely on the burns with little reference to the trauma.
Many used a generic ABCD template without applying it to the patient.
Many answer structures were haphazard with an initial list of the causes followed by the management, with the result that the management for a number of the differentials were missed.
The best answers used a table or bulleted list approach taking about causes as well as management.
Though the college describes this as an "explosion", it is highly unlikely that this patient was exposed to a blast wave (as usually household explosions are of the deflagration variety) and so the discussion will focus mainly on the investigations and management of burns-related hypotension. Blast injury is mentioned in the list as an aside, in response to the comment that most answers "focused solely on the burns with little reference to the trauma".
Thus:
Possible causes of shock in this patient (table adapted from "Causes of Shock in the Trauma Patient")
Type of shock | Cause | Diagnostic strategy |
Artifact of measurement | Blood pressure measurement is inaccurate |
|
Cardiogenic | Cardiac contusion (blast) |
|
Myocardial infarction |
|
|
Arrhythmia |
|
|
Obstructive | Cardiac tamponade |
|
Tension pneumothorax |
|
|
Fat embolism (blast) |
|
|
Neurogenic | Spinal injury |
|
Hypovolemic | Massive blood loss |
|
Massive fluid shift |
|
|
Distributive | Anaphylaxis (induction drugs) |
|
Management, therefore, will consist of the following steps:
Moore, Francis D., et al. "The role of exudate losses in the protein and electrolyte imbalance of burned patients." Annals of surgery 132.1 (1950): 1.
Latenser, Barbara A. "Critical care of the burn patient: the first 48 hours." Critical care medicine37.10 (2009): 2819-2826.
Asch, MORRIS J., et al. "Systemic and pulmonary hemodynamic changes accompanying thermal injury." Annals of surgery 178.2 (1973): 218.
Crum, Ralph L., et al. "Cardiovascular and neurohumoral responses following burn injury."Archives of Surgery 125.8 (1990): 1065-1069.
A previously well 28-year-old male is brought to the Emergency Department following an accident in the garden. He was on a ladder pruning a tree when he touched an overhead power line and was electrocuted. He was thrown to the ground, unconscious and had bystander CPR. Paramedics arrived after 10 minutes, and intubated and ventilated the patient who had return of spontaneous circulation and a Glasgow Coma Scale of 5 at the scene.
a) List the major issues that you would consider in the initial management of this patient. (40% marks)
b) After four days, he develops anuric acute kidney injury (AKI). Describe how you will assess the factors contributing to the AKI. (60% marks)
a)
The potential issues the that need to be considered in this patient include
b)
The assessment of factors contributing to AKI in this setting
Pre-renal causes
Renal causes
Post renal causes
Major issues in the management of the patient:
Part b) asks about the assessment of renal failure in this patient. That's got to be a 6-mark (60%) answer, so it can't just be "send a CK and urinary myoglobin". Sure, the high voltage injury is likely the cause of some deep myonecrosis and this has probably put the patient into a rhabdomyolysis-induced ATN. However that is not the only possibility. Because the patient is complex and may have multiple problems by Day 4, there may be numerous differentials for this AKI. For instance, the 30 minutes of 'down-time" during the cardiac arrest may have given rise to a global hypoxic-ischaemic reperfusion syndrome, and the ATN might be due to that. Or the burns resulting from the electrocution resulted in a prothrombotic state and the patient has developed renal vein thrombosis. Or the IDC is blocked. In short, one would need to deploy a lightly electric-flavoured version of the usual workup for acute kidney injury.
That would look a little like this:
You have been called to the Emergency Department to review a previously well adult male who has sustained a penetrating injury to the root of the neck.
a) Describe the anatomy of the root of the neck on the left side describing the clinically important
structures that may be injured. (50% marks)
b) Outline the issues specific to management of a penetrating neck injury. (50% marks)
a)
The root of the neck is the junction between the thorax and the neck. It opens into, and is the cervical side of, the superior thoracic aperture, through which pass all structures going from the head to the thorax and vice versa
The root of the neck is bound laterally by the first rib, anteriorly by the manubrium, and posteriorly by the T1 vertebrae.
From anterior to posterior, the major contents are:
b)
Examiners Comments:
Generally, poorly answered. Limited knowledge of anatomy and poor structure to answers. A broad approach with a logical approach to prioritisation of investigations/treatments was all that was required to score well. Few candidates commented on general principles of complex trauma requiring input from multiple teams.
This queestion is identical to Question 7 from the second paper of 2015, except this time you have been called to the Emergency Department, not the Emergency Room. Again, the pass rate was under 30%. For future reference, neck anatomy and penetrating neck injury is described in excellent detail by Phillip Thorek in his chapter for Anatomy in Surgery (1985) which is unfortunately paywalled by Springer. So is "Trauma to the neck region" by Saletta et al (1973) and the UpToDate article on penetrating neck injury. For the freegan, Karim Brohi's 2002 write-up of neck wounds on trauma.org is of a high quality.
Brohi divides the neck into three zones, each with its own specific concerns:
(image from trauma.org)
Zone 1:
|
Zone 2 Extends from the cricoid cartilage to the angle of the mandible.
|
Zone 3 Extends from the angle of the mandible to the mastoid process.
|
Specific concerns:
|
Specific concerns:
|
Specific concerns:
|
So, this question is about Zone 1, where all the important stuff is.
b)
A generic approach to management:
Reasons for urgent surgical exploration:
Additional concerns specific to the root of the neck:
Thorek, Philip. "Root of the Neck." Anatomy in Surgery. Springer, New York, NY, 1985. 247-251.
Saletta, John D., Frank A. Folk, and Robert J. Freeark. "Trauma to the neck region." Surgical Clinics of North America53.1 (1973): 73-86.
A 75-year-old male is admitted to your ICU for management of severe chest pain from unilateral rib fractures with a flail segment following major blunt chest trauma. He has no other injuries. He is haemodynamically stable with a respiratory rate of 30 breaths/min and oxygen saturation of 99% on room air.
Discuss the available options for analgesia, including their advantages and disadvantages.
First-line measures
Paracetamol
Intravenous opioid PCA
Second-line measures
IV ketamine infusion 4-16 mg/h
Tramadol
These have the advantages of simplicity and familiarity.
Disadvantages include lack of efficacy, and side effects of sedation, impaired cough, respiratory depression, and agitation or delirium.
Regional anaesthetic techniques
Thoracic Epidural
Benefits
Analgesia is better than with PCA
Better MIP (maximum inspiratory pressure) than with PCA
Avoidance of sedation
Less delirium
Less risk of respiratory depression
Disadvantages
Insertion requires expertise
Risk of failure
Risk of infection
Risk of epidural haematoma
Hypotension
Bradycardia in case of a high block
Intercostal nerve block
Advantages
Simpler than epidural
May require multiple intercostal levels (risk of local anaesthetic toxicity)
Paravertebral catheter infusion
Less effective than epidural, but lower rate of systemic hypotension.
Patients can be discharged to home with a paravertebral catheter in place.
Intrapleural infusion
Relatively contraindicated – NSAIDs, COX-2 inhibitors (risk of renal failure and/or GI bleed)
Although there are no randomized trials comparing the efficacy of these modalities, trauma guidelines recommend epidural analgesia for patients with four or more rib fractures and suggest its use in those with fewer fractures who are older than 65 years or who have significant cardiopulmonary disease or diabetes mellitus.
Other options
Although not a primary analgesic option, invasive or non-invasive mechanical ventilation may reduce analgesic requirements by splinting a large flail segment. Disadvantages of complexity, risks associated with intubation, and IMV, as well as patient discomfort and aspiration risk in NIV
Surgical fixation of the fractures
This has been shown to reduce the chronic pain with non-union and help with the weaning of patients with rib fractures causing flail chest, prevents traumatic thoracoplasty
Disadvantages of invasive procedure with associated risks, may require post-operative ventilation.
Anything that asks for you to discuss advantages and disadvantages of a series of therapeutic options would benefit from a tabulated answer.
Technique | Advantages | Disadvantages |
Systemic opiates +paracetamol |
|
Adverse effects from opiates, especially:
|
NSAIDs |
|
|
Gabapentin and pregabalin |
|
|
Ketamine |
|
|
Epidural |
Analgesia is better than with PCA
|
|
Regional techniques (paraveretebral, intrapleural) |
|
|
Ventilation |
|
|
Surgical fixation |
|
|
Wu, Christopher L., et al. "Thoracic epidural analgesia versus intravenous patient-controlled analgesia for the treatment of rib fracture pain after motor vehicle crash." Journal of Trauma-Injury, Infection, and Critical Care 47.3 (1999): 564-567.
MACKERSIE, ROBERT C., et al. "Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures." Journal of Trauma-Injury, Infection, and Critical Care 31.4 (1991): 443-451.
Kieninger, Alicia N., et al. "Epidural versus intravenous pain control in elderly patients with rib fractures." The American journal of surgery 189.3 (2005): 327-330.
Moon, M. Ryan, et al. "Prospective, randomized comparison of epidural versus parenteral opioid analgesia in thoracic trauma." Annals of surgery 229.5 (1999): 684.
Jarvis, Amy M., et al. "Comparison of epidural versus parenteral analgesia for traumatic rib fractures: a meta-analysis." OPUS 12 (2009): 50-57.
Galvagno Jr, Samuel Michael, et al. "Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society." Journal of Trauma and Acute Care Surgery 81.5 (2016): 936-951.
Curtis, Kate, et al. "ChIP: An early activation protocol for isolated blunt chest injury improves outcomes, a retrospective cohort study." Australasian Emergency Nursing Journal 19.3 (2016): 127-132.
Carrie, Cédric, et al. "Bundle of care for blunt chest trauma patients improves analgesia but increases rates of intensive care unit admission: A retrospective case-control study." Anaesthesia Critical Care & Pain Medicine 37.3 (2018): 211-215.
Galvagno Jr, Samuel Michael, et al. "Pain management for blunt thoracic trauma: a joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society." Journal of Trauma and Acute Care Surgery 81.5 (2016): 936-951.
Zaw, Andrea A., et al. "Epidural analgesia after rib fractures." The American Surgeon 81.10 (2015): 950-954.
Peek, Jesse, et al. "Comparison of analgesic interventions for traumatic rib fractures: a systematic review and meta-analysis." European Journal of Trauma and Emergency Surgery (2018): 1-26.
Karmakar, Manoj K., and Anthony M-H. Ho. "Acute pain management of patients with multiple fractured ribs." Journal of Trauma and Acute Care Surgery 54.3 (2003): 615-625.
Beks, Reinier B., et al. "Fixation of flail chest or multiple rib fractures: current evidence and how to proceed. A systematic review and meta-analysis." European Journal of Trauma and Emergency Surgery (2018): 1-14.
With regard to fat embolism syndrome (FES), outline the precipitants, clinical features, diagnosis and management
Precipitants:
Trauma-related
Orthopaedic (most common)
Long bone fracture (esp femur)
Pelvic fracture
Elective Orthopaedic surgery
Non-orthopaedic
Liposuction
BM harvest/transplant
Nontrauma-related
Acute pancreatitis
Sickle cell disease
Clinical features
Typically develops 24-72 hours following insult.
Classic clinical triad (neurological, respiratory, cutaneous), none of which is specific for FES.
• Respiratory – the most common presenting feature. Dyspnoea, hypoxia, ARDS
• Neurological – confusion, reduced level of consciousness, seizure, focal deficit, retinal changes (petechiae)
• Petechial rash – usually in non-dependent areas, including neck, axillae, anterior chest, head, subconjunctiva. Only in 1/3 of cases, and often not until 3-5 days after insult.
Other – fever, thrombocytopenia, coagulation abnormalities (incl DIC), anaemia, tachycardia, myocardial depression, renal/liver dysfunction, high ESR
Diagnosis
Based on the clinical features in the setting of known precipitant
CXR may reveal bilateral patchy infiltrates
No single diagnostic test – BAL sampling for lipids has been described – no other tests shown to be useful
Several sets of diagnostic criteria proposed
Management
Prevention clearly preferable if possible – e.g. surgical timing (following fracture) and technique Fixation of fracture
No specific therapy. Supportive only.
Steroids controversial – proposed anti-inflammatory effect but limited data to support
Precipitants
Traumatic | Unrelated to trauma |
|
|
Clinical features
Symptoms of fat embolism
Signs of fat embolism
Diagnosis
Gurd's Criteria Major criteria
Minor criteria
|
Lindeque's criteria
Schonfeld criteria
|
Laboratory features:
Characteristic imaging:
Management:
Mellor, A., and N. Soni. "Fat embolism." Anaesthesia 56.2 (2001): 145-154.
Gurd, Alan R., and R. I. Wilson. "The fat embolism syndrome." Journal of Bone & Joint Surgery, British Volume 56.3 (1974): 408-416.
Myers, R., and J. J. Taljaard. "Blood alcohol and fat embolism syndrome." J Bone Joint Surg Am 59.7 (1977): 878-880.
Hofmann, S., G. Huemer, and M. Salzer. "Pathophysiology and management of the fat embolism syndrome." Anaesthesia 53.S2 (1998): 35-37.
Kosova, Ethan, Brian Bergmark, and Gregory Piazza. "Fat Embolism Syndrome." Circulation 131.3 (2015): 317-320.
Jain, S., et al. "Fat embolism syndrome." JAPI 56 (2008): 245-249.
Gupta, Amandeep, and Charles S. Reilly. "Fat embolism." Continuing education in anaesthesia, critical Care & pain 7.5 (2007): 148-151.
a) Define heat stroke and describe the two forms of heatstroke, highlighting the differences between these two conditions. (20% marks)
b) Describe the clinical features of heatstroke and the biochemical and haematological changes that may occur. (40% marks)
c) Discuss the cooling strategies in heat stroke. (40% marks)
a) Heat stroke is defined as a core body temperature usually in excess of 40ºC with associated central nervous system dysfunction in the setting of a large environmental heat load that cannot be dissipated. Classic (nonexertional heat stroke) affects elderly individuals with underlying chronic medical conditions that impair thermoregulation, prevent removal from a hot environment, or interfere with access to hydration or attempts at cooling. These conditions include cardiovascular disease, neurologic or psychiatric disorders, obesity, anhidrosis, physical disability, extremes of age, and the use of recreational drugs and certain prescription drugs. Exertional heat stroke generally occurs in young, otherwise healthy individuals who engage in heavy exercise during periods of high ambient temperature and humidity. (2 marks)
b) The first clinical signs are often neurological and may include restlessness, delirium, seizures and coma. Multiple organ involvement may occur including signs of distributive shock with a hyperdynamic profile with hypovolaemia as a consequence of dehydration and reduced organ perfusion and associated lactic acidosis. There may be hyperventilation with respiratory alkalosis and hypoxia from acute lung injury. The main biochemical abnormalities include hyperglycaemia, hypophosphataemia, raised hepatic and muscular enzymes and an elevation of acute phase proteins. The haematological findings include leucocytosis, thrombocytopenia and activation of coagulation and fibrinolysis. (4 marks)
c) Cooling Strategies in Heat Stroke:
Methods:
Water and fan: Evaporative and convective cooling:
Body sprayed with lukewarm water and fans are used to blow air over the moist skin.
Suppression of heat:
Agitated and shivering patient can generate heat. That can be suppressed with the use of benzodiazepines (such as lorazepam, midazolam) and chlorpromazine paralysing agents may be required
Cold water immersion:
Immersion of patient in ice water: non-invasive, rapid but makes patient monitoring difficult
Application of ice packs:
Ice packs can be placed in axillae, neck and groin: excellent method for intubated patient, poorly tolerated by non- intubated patients
Cold compressors:
Can be applied on smooth, hairless surfaces like: palms, cheeks, soles: rapid cooling
Cold thoracic, gastric and peritoneal lavage: invasive but rapid
Cooling catheters: invasive, rapid
Cooling blankets: non-invasive, can set the temperature
Cold IV fluids
Cooling recommendations are primarily based on observation studies
There is no definitive study supporting any particular approach to cooling in classic heat stroke
Pharmacological agents like dantrolene are ineffective and not indicated in heat stroke
Alcohol sponge baths should be avoided due to risk of absorption of alcohol through skin
Definition of heat stroke
Exertional heat stroke
Non-exertional heat stroke
Clinical signs of heat stroke
Characteristic laboratory findings in heat stroke
Cooling strategies for heat stroke
There is not specific approach which is thought to be more effective than other approaches. For instance, in a letter to Intensive Care Medicine, Hadad et al (2005) pointed out that in the Israeli Defence Forces, with tap water and a fan one is able to achieve a core temperature rate drop of 1°C every 9 minutes. Costrini (1990), looking at different ways of cooling down overheated athletes, suggested ice water immersion to be the best method. A more detailed discussion of cooling methods is carried out in the chapter on inducing therapeutic hypothermia. The college, in their answer to Question 22 from the second paper of 2018, mention alcohol sponge baths as a discredited alternative. This practice has been discredited since the 1960s, when it killed children (Senz et al, 1959) and adults (Wise, 1969) by producing a surprising amount of alcohol absorption (they were using mainly isopropyl "rubbing" alcohol). On the other hand, if your objective is to achieve heroic levels of intoxication, percutaneous obsorption is a valid method (Puschel et al, 1981).
Bouchama, Abderrezak, and James P. Knochel. "Heat stroke." New England Journal of Medicine 346.25 (2002): 1978-1988.
Grogan, H., and P. M. Hopkins. "Heat stroke: implications for critical care and anaesthesia." British Journal of Anaesthesia 88.5 (2002): 700-707.
Glazer, James L. "Management of heatstroke and heat exhaustion." Am Fam Physician 71.11 (2005): 2133-2140.
Shahid, Maie S., et al. "Echocardiographic and Doppler study of patients with heatstroke and heat exhaustion." The International Journal of Cardiac Imaging 15.4 (1999): 279-285.
Bricknell, M. C. "Heat illness--a review of military experience (Part 1)." Journal of the Royal Army Medical Corps 141.3 (1995): 157-166.
Bricknell, M. C. M. "Heat illness-A review of military experience (Part 2)." Journal of the Royal Army Medical Corps 142.1 (1996): 34-42.
Buggy, D. J., and A. W. Crossley. "Thermoregulation, mild perioperative hypothermia and post-anaesthetic shivering." British Journal of Anaesthesia 84.5 (2000): 615-628.
Rowell, L. B. "Cardiovascular aspects of human thermoregulation." Circulation Research 52.4 (1983): 367-379.
Deschamps, A., et al. "Effect of saline infusion on body temperature and endurance during heavy exercise." Journal of Applied Physiology 66.6 (1989): 2799-2804.
Buckley, I. K. "A light and electron microscopic study of thermally injured cultured cells." Laboratory investigation; a journal of technical methods and pathology 26.2 (1972): 201.
Bynum, GAITHER D., et al. "Induced hyperthermia in sedated humans and the concept of critical thermal maximum." American Journal of Physiology-Regulatory, Integrative and Comparative Physiology 235.5 (1978): R228-R236.
Leon, Lisa R., and Bryan G. Helwig. "Heat stroke: role of the systemic inflammatory response." Journal of applied physiology 109.6 (2010): 1980-1988.
Alzeer, Abdulaziz H., et al. "Serum enzymes in heat stroke: prognostic implication." Clinical chemistry 43.7 (1997): 1182-1187.
Bouchama, Abderrezak, Mohammed Dehbi, and Enrique Chaves-Carballo. "Cooling and hemodynamic management in heatstroke: practical recommendations." Crit Care 11.3 (2007): R54.
Misset, Benoît, et al. "Mortality of patients with heatstroke admitted to intensive care units during the 2003 heat wave in France: A national multiple-center risk-factor study*." Critical care medicine 34.4 (2006): 1087-1092.
BOUCHAMA, ABDERREZAK, et al. "Ineffectiveness of dantrolene sodium in the treatment of heatstroke." Critical care medicine 19.2 (1991): 176-180.
Adams, Tom, et al. "Exertional heat stroke." British Journal of Hospital Medicine 73.2 (2012): 72-78.
Hadad, Eran, Daniel S. Moran, and Yoram Epstein. "Cooling heat stroke patients by available field measures." Intensive care medicine 30.2 (2004): 338-338.
Costrini, Anthony. "Emergency treatment of exertional heatstroke and comparison of whole body cooling techniques." Medicine and Science in Sports and Exercise22.1 (1990): 15-18.
Senz, Edward H., and Donald L. Goldfarb. "Coma in a child following use of isopropyl alcohol in sponging." The Journal of pediatrics 53.3 (1958): 322-323.
Wise, Jr JR. "Alcohol sponge baths." The New England journal of medicine 280.15 (1969): 840-840.
Püschel, Klaus. "Percutaneous alcohol intoxication." European journal of pediatrics 136.3 (1981): 317-318.
Knochel, James P., and Jennifer H. Caskey. "The mechanism of hypophosphatemia in acute heat stroke." Jama 238.5 (1977): 425-426.
A 37-year-old male has been admitted to your ICU following an explosion in his garage. He has suffered a mixture of partial and deep burns estimated at 35% total body surface area, and he has been intubated in the Emergency Department. After one hour of resuscitation in your unit he remains hypotensive with a blood pressure of 80/50 mmHg.
List the potential causes and outline how you would diagnose and manage them.
Examiners Comments:
Frequently poorly structured answer, with a list of causes of hypotension, then repeated with diagnosis and management. Worked better when candidates classified each category of shock, then described individual diagnosis and management within each category. Often the question had not been carefully read, and the time already spent in ED and ICU was ignored; then a simplistic EMST initial approach to trauma was given.
This question resembles Question 26 from the second paper of 2016, except the patient is not unconscious and there is no ABG to interpret.
Let this be an exercise in generating differentials.
If one were to offer more detail, one would have to tabulate one's answer, which would handily answer complaints about a lack of structure, because nothing says "structure" like a table.
Type of shock | Cause | Diagnostic strategy | Management |
Artifact of measurement | Arterial blood pressure measurement is inaccurate | Compare with non-invasive measurement and physical examination |
|
Cardiogenic | Cytokine-induced myocardial dysfunction Alternatively, cardiac dysfunction can be associated with cyanide and carbon monoxide toxicity |
TTE, ECG, cardiac output measurement by PiCCO or PA catheter |
|
Myocardial infarction | TTE, ECG, cardiac enzymes |
|
|
Obstructive | Abdominal compartment syndrome | Measure the intra-abdominal pressure; calculate total fluid resuscitation (it is associated with over-resuscitation) |
|
Massive pulmonary embolism (unlikely - too early - more likely in the chronic recovery from burns) |
TTE, CVP trace, ECG, CTPA |
|
|
Tension pneumothorax (likely, if there the patient was in some sort of explosion) |
Physical examination; CXR |
|
|
Neurogenic | Spinal injury due to fall; may have gone unrecognised given that the patient was found unconscious | Physical examination features, CT, MRI |
|
Hypovolemic | Blood loss | Examination of the patient, FBC, DIC screen |
|
Under-resuscitated burns shock | Compare fluid resuscitation with predicted expectations as based on the formulae |
|
|
Distributive | Vasoplegia due to SIRS | SVRI measurements by PiCCO |
|
Anaphylaxis | Physical examination findings suggestive of angioedema |
|
|
Cytotoxic | Cyanide toxicity due to smoke inhalation | Lactate levels; cyanide levels |
|
Mitra, Biswadev, et al. "Fluid resuscitation in major burns." ANZ journal of Surgery 76.1‐2 (2006): 35-38.
Haberal, Mehmet, A. Ebru Sakallioglu Abali, and Hamdi Karakayali. "Fluid management in major burn injuries." Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India 43.Suppl (2010): S29.
Fodor, Lucian, et al. "Controversies in fluid resuscitation for burn management: Literature review and our experience." Injury 37.5 (2006): 374-379.
Bak, Zoltan, et al. "Hemodynamic changes during resuscitation after burns using the Parkland formula." Journal of Trauma and Acute Care Surgery 66.2 (2009): 329-336.
Blumetti, Jennifer, et al. "The Parkland formula under fire: is the criticism justified?." Journal of burn care & research 29.1 (2008): 180-186.
Baxter, Charles R., and Tom Shires. "Physiological response to crystalloid resuscitation of severe burns." Annals of the New York Academy of Sciences 150.3 (1968): 874-894.
Saffle, Jeffrey R. "The phenomenon of “fluid creep” in acute burn resuscitation." Journal of burn care & research 28.3 (2007): 382-395.
Naver, P. D., J. R. Saffle, and G. D. Warden. "Effect of inhalation injury on fluid resuscitation requirements after thermal injury." Plastic and Reconstructive Surgery 78.4 (1986): 550.
Arlati, S., et al. "Decreased fluid volume to reduce organ damage: a new approach to burn shock resuscitation? A preliminary study." Resuscitation 72.3 (2007): 371-378.
Bittner, Edward A., et al. "Acute and Perioperative Care of the Burn-Injured Patient." Survey of Anesthesiology 59.3 (2015): 117.
Melinyshyn, Alex, et al. "Albumin supplementation for hypoalbuminemia following burns: unnecessary and costly!." Journal of Burn Care & Research 34.1 (2013): 8-17.
Cooper, Andrew B., et al. "Five percent albumin for adult burn shock resuscitation: lack of effect on daily multiple organ dysfunction score." Transfusion 46.1 (2006): 80-89.
Wilkes, NICHOLAS J. "Hartmann's solution and Ringer's lactate: targeting the fourth space." Clinical Science 104.1 (2003): 25-26.
MONAFO, WILLIAM W. "The treatment of burn shock by the intravenous and oral administration of hypertonic lactated saline solution." Journal of Trauma and Acute Care Surgery 10.7 (1970): 575-586.
Huang, Peter P., et al. "Hypertonic sodium resuscitation is associated with renal failure and death." Annals of surgery 221.5 (1995): 543.
Sun, Ye-Xiang, et al. "Effect of 200 mEq/L Na+ hypertonic saline resuscitation on systemic inflammatory response and oxidative stress in severely burned rats." Journal of Surgical Research 185.2 (2013): 477-484.
Paratz, Jennifer D., et al. "Burn Resuscitation—Hourly Urine Output Versus Alternative Endpoints: A Systematic Review." Shock 42.4 (2014): 295-306.
Walker, Steven C., et al. "Balanced Electrolyte Solution Reduces Acidosis as Compared to Normal Saline in the Resuscitation of Perioperative Burn Patients." Anesthesiology 95 (2001): A375
With respect to the management of a multi-trauma patient requiring mechanical ventilation; describe the injuries that require specific positioning or immobilisation of the patient and the strategies used in this context. Include in your answer how these strategies impact upon the care of the patient.
Patients with "unstable" injuries may be at risk of secondary injury if passive or active movements are not limited.
Brain- Traumatic Brain Injury:
C-Spine injury
Thoraco-lumbar spine injury
Pelvic fractures
Long bone fractures
Other points
Competing injuries- precautions should relate to the most serious identified injury - e.g. a cleared spine may mean a patient can be sat up, but not in the setting of a co-existing mechanically unstable pelvis.
Likewise:
Urgency exists in identifying injuries at the earliest possible time (secondary and tertiary survey) in order to remove or increase position restrictions for the individual patient.
Emphasis should be on own practice, no single "right way" but sensible risk/benefit-based approach including clinical and radiologic findings to guide practice.
Examiners Comments:
Poor discussion on competing priorities and how to manage this. Many answers lacked detail and/or did not really address all aspects of the question and were at junior registrar level. Some answers included injuries/complications/strategies not related to positioning or immobilisation
This question is identical to Question 19 from the first paper of 2014
Positioning for head injury
Positioning for C-spine injury
Positioning for T/L spine injuries
Positioning for severe chest injuries
Positioning in pelvic fractures
Positioning in long bone fractures
Positioning for the pregnant trauma patient
Competing interest
Christie, Robert James. "Therapeutic positioning of the multiply-injured trauma patient in ICU." British Journal of Nursing 17.10 (2008): 638-642.
You have received a call from a junior doctor at a rural hospital awaiting retrieval for a 40-year-old male who has just presented with severe burns after a gas canister explosion.
How will you guide the junior doctor through the assessment of the patient? (Details about the management are not required).
Initial assessment of patient:
Examiners Comments:
A number of candidates gave long lists of investigations and personnel only available in a large centre- candidates were marked down for this though not failed if the rest of the answer was of an acceptable standard
Assessment of the burns patent in this SAQ scenario was made more flavourful by the additional complexity of telemedicine. What would you ask this junior doctor to look for, and how would you describe the findings over the phone? This is a pleasant variation on the same theme as Question 16 from the second paper of 2019, Question 26 from the second paper of 2016, Question 18 from the second paper of 2012, and so forth.
The BMJ had published a series of 12 articles, titled "the ABC of burns".
These are a valuable resource. Some are linked to below:
Devgan, Lara, et al. "Modalities for the assessment of burn wound depth."Journal of burns and wounds (2006) 5: e2.
Heimbach, David M., et al. "Burn Depth Estimation-Man or Machine." Journal of Trauma and Acute Care Surgery 24.5 (1984): 373-378.
Johnson, R. Michael, and Reg Richard. "Partial-thickness burns: identification and management." Advances in skin & wound care 16.4 (2003): 178-187.
Discuss the role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in resuscitation. Include in your answer: brief description, mechanism of action, potential indications, contraindications, and complications.
Introduction/ Description
REBOA, by inflation of balloon at specific zones of the aorta to interrupt blood flow, haemorrhage below the level of the balloon can be controlled, while augmentation of the blood pressure cranial to the balloon. It allows temporary control of non-compressible intra-abdominal bleeding in order to proceed for definitive operation.
Has been used in many locations:
Intra-operatively, in the emergency department, interventional radiology and in the field.
Mechanism of action
Provides increase in afterload similar to a balloon pump. However, there is no deflation. Downstream stops haemorrhage by occlusion of vessel. Increases MAP during this time and consequently cerebral and myocardial perfusion.
Potential Indications of REBOA
-AAA rupture,
-Post-partum haemorrhage
- Abdominal or pelvic bleeding any cause i.e. elective surgical complication
Contraindication:
Complications
Brief description:
Mechanism of action:
Potential indications:
Absolute contraindications are:
Relative contraindications include:
Complications:
Fitzgerald, Mark, et al. "Feasibility study for implementation of resuscitative balloon occlusion of the aorta in peri‐arrest, exsanguinating trauma at an adult level 1 Australian trauma centre." Emergency Medicine Australasia (2019).
Manning, James E. "Selective aortic arch perfusion." U.S. Patent No. 5,437,633. 1 Aug. 1995.
Kutcher, Matthew E., Raquel M. Forsythe, and Samuel A. Tisherman. "Emergency preservation and resuscitation for cardiac arrest from trauma." International Journal of Surgery 33 (2016): 209-212.
Stannard, Adam, Jonathan L. Eliason, and Todd E. Rasmussen. "Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock." Journal of Trauma and Acute Care Surgery 71.6 (2011): 1869-1872.
Hughes, Carl W. "Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man." Surgery 36.1 (1954): 65-68.
Ledgerwood, ANNA M., M. A. R. I. S. Kazmers, and CHARLES E. Lucas. "The role of thoracic aortic occlusion for massive hemoperitoneum." The Journal of trauma 16.08 (1976): 610-615.
Napolitano, Lena M. "Resuscitative endovascular balloon occlusion of the aorta: indications, outcomes, and training." Critical care clinics 33.1 (2017): 55-70.
Low, Ronald B., et al. "Preliminary report on the use of the percluder® occluding aortic balloon in human beings." Annals of emergency medicine 15.12 (1986): 1466-1469.
Gupta, Bhupendra K., et al. "The role of intra-aortic balloon occlusion in penetrating abdominal trauma." The Journal of trauma 29.6 (1989): 861-865.
Martinelli, Thomas, et al. "Intra-aortic balloon occlusion to salvage patients with life-threatening hemorrhagic shocks from pelvic fractures." Journal of Trauma and Acute Care Surgery 68.4 (2010): 942-948.
Patel, Jigarkumar A., and Joseph M. White. "REBOA-Induced Ischemia-Reperfusion Injury." Endovascular Resuscitation and Trauma Management. Springer, Cham, 2020. 121-133.
Stannard, Adam, Jonathan L. Eliason, and Todd E. Rasmussen. "Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock." Journal of Trauma and Acute Care Surgery 71.6 (2011): 1869-1872.
Cannon, Jeremy, et al. "Resuscitative endovascular balloon occlusion of the aorta (REBOA) for hemorrhagic shock." Military medicine 183.suppl_2 (2018): 55-59.
Chung, Jae Sik, et al. "resuscitative Endovascular Balloon occlusion of the aorta in Impending Traumatic arrest: Is It Effective?." Journal of Trauma and Injury (2020).
Yamamoto, Ryo, et al. "Resuscitative endovascular balloon occlusion of the aorta (REBOA) is associated with improved survival in severely injured patients: A propensity score matching analysis." The American Journal of Surgery 218.6 (2019): 1162-1168.
Bekdache, Omar, et al. "Resuscitative endovascular balloon occlusion of the aorta (REBOA): a scoping review protocol concerning indications—advantages and challenges of implementation in traumatic non-compressible torso haemorrhage." BMJ open 9.2 (2019): e027572.
Nunez, Ramiro Manzano, et al. "A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients." World Journal of Emergency Surgery 12.1 (2017): 30.
van der Burg, BLS Borger, et al. "A systematic review and meta-analysis of the use of resuscitative endovascular balloon occlusion of the aorta in the management of major exsanguination." European Journal of Trauma and Emergency Surgery 44.4 (2018): 535-550.
How would you reduce the red cell transfusion requirements in an actively bleeding multiple trauma patient?
Early recognition and identification of location of bleeding (0.5)
Early haemorrhage control with basic haemostatic measures including: (1)
-Direct pressure
-Use of staples for soft tissue bleeding e.g. scalp bleeding
-Use of tourniquets in traumatic amputations
-Avoiding scene delays
Early definitive haemorrhage control with surgery or angiographic techniques (0.5) Avoidance of excessive crystalloid infusion. (0.5)
“Permissive hypotension” is a fluid restriction strategy that limits dilutional coagulopathy, potentially limits clot dislodgement by maintaining a SBP 80-90mmHg.
Initial RCT single centre research (Bickel 1994 NEMJ) in penetrating torso injures showed mortality benefit in delayed fluid resuscitation. Further multi centre RCT research with blunt trauma confirmed the improved mortality in the permissive hypotension group.
The controversy exists in the presence of TBI (traumatic brain injury) and Spinal cord injury (SCI) and the avoidance of secondary brain injury. Brain trauma foundation guidelines aim for an SBP >90 or CPP > 60 to prevent this. Permissive hypotension is not suitable for these patients. There is no evidence for Hb level. The TRICC trial excluded these patients (1.5)
Avoid the lethal triad of hypothermia, acidosis, and coagulopathy.(0.5 mark each) Ensure an ionised Ca2+ > 1 mmol/l. (0.5)
Maintaining fibrinogen > 1.5 g/L. (0.5)
Maintaining platelets > 100 x 109 /L. (0.5)
Recognition of the presence of medications causing coagulopathy or platelet dysfunction such as aspirin, clopidogrel, warfarin or a novel oral anticoagulant. In this instance the provision of platelets, FFP or prothrombin concentrate complexes may be appropriate. (1)
Point of care testing such as thromboelastography to facilitate rapid and targeted coagulopathy correction. (1)
The use of tranexamic acid < 3 hours (CRASH2). (0.5) Appropriate cessation of the massive bleeding protocol. (0.5)
Prevent further haemoglobin loss:
Prevent wasteful use of blood products:
Support haemopoiesis:
Exotic techniques
Tinmouth, Alan T., Lauralynn A. McIntyre, and Robert A. Fowler. "Blood conservation strategies to reduce the need for red blood cell transfusion in critically ill patients." Cmaj 178.1 (2008): 49-57.
Egea-Guerrero, J. J., et al. "Resuscitative goals and new strategies in severe trauma patient resuscitation." Medicina Intensiva (English Edition) 38.8 (2014): 502-512.
Tien, Homer, et al. "An approach to transfusion and hemorrhage in trauma: current perspectives on restrictive transfusion strategies." Canadian journal of surgery 50.3 (2007): 202.
Morrison, J. J., et al. "Intra‐operative correction of acidosis, coagulopathy and hypothermia in combat casualties with severe haemorrhagic shock." Anaesthesia 68.8 (2013): 846-850.
Duchesne, Juan C., et al. "Damage control resuscitation in combination with damage control laparotomy: a survival advantage." Journal of Trauma and Acute Care Surgery 69.1 (2010): 46-52.
a) Define intra-abdominal hypertension (IAH) and intra-abdominal compartment syndrome (ACS). (20% marks)
b) Describe how intra-abdominal pressure (IAP) is commonly measured. (40% marks)
c) Briefly outline the management principles of intra-abdominal compartment syndrome (ACS). (40% marks)
Not available.
a) Definitions
b) Measurement
c) Management of abdominal compartment syndrome:
Malbrain, Manu LNG, et al. "Results from the international conference of experts on intra-abdominal hypertension and abdominal compartment syndrome. I. Definitions." Intensive care medicine 32.11 (2006): 1722-1732.
Cheatham, Michael L., et al. "Abdominal perfusion pressure: a superior parameter in the assessment of intra-abdominal hypertension." Journal of Trauma-Injury, Infection, and Critical Care 49.4 (2000): 621-627.
Bailey, Jeffrey, and Marc J. Shapiro. "Abdominal compartment syndrome."Critical Care 4.1 (2000): 23.
Cheatham, Michael Lee. "Abdominal compartment syndrome." Current opinion in critical care 15.2 (2009): 154-162.
Maerz, Linda, and Lewis J. Kaplan. "Abdominal compartment syndrome."Critical care medicine 36.4 (2008): S212-S215.
Saggi, Bob H., et al. "Abdominal compartment syndrome." Journal of Trauma-Injury, Infection, and Critical Care 45.3 (1998): 597-609.
With respect to management of the cervical spine in an intubated ICU patient who has suffered a multi- trauma:
a) What are the advantages and disadvantages of radiological clearance of the cervical spine with MRI compared to CT? (40% marks)
b) List the complications of prolonged immobilisation when spinal precautions are used for a suspected cervical-spine injury. (60% marks)
Not available.
Modality | Advantages | Disadvantages |
CT |
|
|
MRI |
|
|
Complications of prolonged C-spine immobilisation from a 2004 review by Morris and McCoy
The Alfred Spinal Clearance Protocol
Chapter 78 (pp. 795) Spinal injuries by Sumesh Arora and Oliver J Flower
Lien, D., T. Jacques, and K. Powell. "Cervical spine clearance in Australian intensive care units." Critical Care and Resuscitation 5.2 (2003): 91.
Cooper, D. J., and H. M. Ackland. "Clearing the cervical spine in unconscious head injured patients-the evidence." Critical Care and Resuscitation 7.3 (2005): 181.
Hennessy, Deirdre, et al. "Cervical spine clearance in obtunded blunt trauma patients: a prospective study." The Journal of Trauma and Acute Care Surgery68.3 (2010): 576-582.
Como, John J., et al. "Is magnetic resonance imaging essential in clearing the cervical spine in obtunded patients with blunt trauma?." Journal of Trauma-Injury, Infection, and Critical Care 63.3 (2007): 544-549.
Tran, Baotram, Jonathan M. Saxe, and Akpofure Peter Ekeh. "Are flexion extension films necessary for cervical spine clearance in patients with neck pain after negative cervical CT scan?." Journal of Surgical Research 184.1 (2013): 411-413.
Sierink, J. C., et al. "Systematic review of flexion/extension radiography of the cervical spine in trauma patients." European journal of radiology 82.6 (2013): 974-981.
Patel, Mayur B., et al. "Cervical spine collar clearance in the obtunded adult blunt trauma patient: A systematic review and practice management guideline from the Eastern Association for the Surgery of Trauma." Journal of Trauma and Acute Care Surgery 78.2 (2015): 430-441.
Morris, C. G. T., and E. McCoy. "Clearing the cervical spine in unconscious polytrauma victims, balancing risks and effective screening." Anaesthesia 59.5 (2004): 464-482.
Richards, Paula J. "Cervical spine clearance: a review." Injury 36.2 (2005): 248-269.
Hoffman, Jerome R., et al. "Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma." New England Journal of Medicine 343.2 (2000): 94-99.
Stiell, Ian G., et al. "The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma." New England Journal of Medicine 349.26 (2003): 2510-2518.
Stiell, Ian G., et al. "The Canadian C-spine rule for radiography in alert and stable trauma patients." Jama 286.15 (2001): 1841-1848.
Jo, Alexandria S., et al. "Essentials of spine trauma imaging: radiographs, CT, and MRI." Seminars in Ultrasound, CT and MRI. Vol. 39. No. 6. WB Saunders, 2018.
Malhotra, Ajay, et al. "Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT." European radiology 28.7 (2018): 2823-2829.
You are called to the Emergency Department to review a 56-year-old female found floating in the surf. Her initial rhythm was asystole, although return of spontaneous circulation was achieved within 5 minutes of ambulance arrival. She is currently intubated with a correctly positioned endotracheal tube, is being ventilated adequately with 100% oxygen, and has an unsupported blood pressure of 130/65 mmHg.
What are the management issues that must be considered in her further care? For each issue briefly outline any specific interventions or treatments required.
(Note to candidates: general details of resuscitation such as providing standard monitoring or obtaining vascular access are not required.)
Not available.
Emergency management issues
ICU management issues
The ARC ALS2 manual (2011) has a section on drowning (pp. 127). This was my main source of information.
Pearn, John. "The management of near drowning." British medical journal (Clinical research ed.) 291.6507 (1985): 1447.
Giammona, Samuel T., and Jerome H. Modell. "Drowning by total immersion: effects on pulmonary surfactant of distilled water, isotonic saline, and sea water." American Journal of Diseases of Children 114.6 (1967): 612-616.
Modell, Jerome H., et al. "Physiologic effects of near drowning with chlorinated fresh water, distilled water and isotonic saline." Anesthesiology 27.1 (1966): 33-41.
Young, Richard SK, Edwin L. Zalneraitis, and Elizabeth C. Dooling. "Neurological outcome in cold water drowning." Jama 244.11 (1980): 1233-1235.
Szpilman, David, et al. "Drowning." New England journal of medicine 366.22 (2012): 2102-2110.
Modell, Jerome H., and J. H. Davis. "Electrolyte changes in human drowning victims." Anesthesiology 30.4 (1969): 414.
Modell, Jerome H., et al. "The effects of fluid volume in seawater drowning." Annals of internal medicine 67.1 (1967): 68-80.
Halmagyi, Denis FJ. "Lung changes and incidence of respiratory arrest in rats after aspiration of sea and fresh water." Journal of applied physiology 16.1 (1961): 41-44.
Fuller, Roger H. "The clinical pathology of human near-drowning." Proceedings of the Royal Society of Medicine 56.1 (1963): 33.
A morbidly obese 49-year-old female is referred from the Emergency Department to ICU following a motor vehicle crash and has left sided fractured ribs and a flail chest. She has seatbelt bruising over her chest wall and abdomen. She has had a CT scan of head, neck, chest, abdomen and pelvis that has shown left rib fractures and left sided lung infiltrates. There are no other injuries evident. She is receiving oxygen via a Hudson mask, is conscious and has significant left sided pleuritic chest pain.
Discuss the differences in management of this patient compared to a non-obese patient.
Not available.
The differences in management of this patient compared to a non-obese patient:
A different pattern of injury is to be expected:
Differences in managing the airway of a morbidly obese trauma patient:
Differences in managing the ventilation of a morbidly obese trauma patient:
Difference in managing haemodynamics in a morbidly obese trauma patient:
Difference in managing sedation, analgesia and C-spine protection in the morbidly obese trauma patient
Differences in the investigations
Bochicchio, Grant V., et al. "Impact of obesity in the critically ill trauma patient: a prospective study." Journal of the American College of Surgeons 203.4 (2006): 533-538.
Diaz Jr, Jose J., et al. "Morbid obesity is not a risk factor for mortality in critically ill trauma patients." Journal of Trauma and Acute Care Surgery 66.1 (2009): 226-231.
Lambert, David M., Simon Marceau, and R. Armour Forse. "Intra-abdominal pressure in the morbidly obese." Obesity surgery 15.9 (2005): 1225-1232.
Boulanger, Bernard R., et al. "Body habitus as a predictor of injury pattern after blunt trauma." Journal of Trauma and Acute Care Surgery 33.2 (1992): 228-232.
Dhungel, Vinayak, et al. "Obesity delays functional recovery in trauma patients." journal of surgical research 193.1 (2015): 415-420.
Ciesla, David J., et al. "Obesity increases risk of organ failure after severe trauma." Journal of the American College of Surgeons 203.4 (2006): 539-545.
Arbabi, Saman, et al. "The cushion effect." Journal of Trauma and Acute Care Surgery 54.6 (2003): 1090-1093.
Evans, David C., et al. "Obesity in trauma patients: correlations of body mass index with outcomes, injury patterns, and complications." The American surgeon 77.8 (2011): 1003-1008.
Fuchs, I., et al. "Vascular Injury in Obese Patients after Ultra-Low-Velocity Trauma." J Anesth Clin Res 5.488 (2014): 2.