Printable list of all the trauma SAQs

College Answer

Candidates failed to understand the effects of a C4-5 lesion. There has obviously been a quick assessment of the patient so that  we are told of paralysis and sensory  level. Being a surfing injury, and not a high speed MVA, associated injuries may include hypoxia and near drowning.

(a) The  candidate  should  have  had  an  appropriate  hierarchy  of  priorities  from  this  point. Textbook lists are inadequate. Actions should have been explained and related to the case. GCS and airway  patency should  be checked  but  if a sensory  level  could be accurately ascertained, the patient is possibly talking and maintaining an airway.

Breathing will be of prime concern. A level at C4-5, perhaps complete, would produce loss of all intercostal and  some  diaphragmatic  function. With  his  age and  history  of  heavy smoking it is likely that intubation would be necessary. A clinical assessment ·of respiration and breathing pattern should be clearly elucidated, not just listed.

A safe technique for intubation should be detailed if the decision is to proceed (eg. blind nasal, 'rapid sequence' or fibre-optic bronchoscopic with in-line traction).

Blood  pressure  support:  bradycardia  and  relative  hypotension  are  expected.  If  organ perfusion is adequate, no action is necessary. An associated head injury will necessitate the use of inoconstrictor to maintain CPP or blood loss (eg. from ruptured spleen) will require volume resuscitation.

The candidate should then cover:

•  Diagnosis:
- history (recent and past)
- complete assessment of neurological function survey for other injuries
- investigations: ( 3 view x-ray),
- CT or MRI (why, pros and cons),
- CXR

•  Treatment:
- steroids: the NASCIS II study showed motor and sensory improvement with
methylprednisolone 30mglkg bolus and 5.4mglkg infusion over 23hrs. Criticised
widely and not used by all but the evidence of benefit is accumulating.
- surgical Vs medical treatment and early Vs late are undecided  issues. Most surgeons would decompress a patient with incomplete lesion and significant canal narrowing
- NG tube - ileus
- IDC - urinary retention leads to bladder problems long term
- Temperature maintenance
- DVT prophylaxis
- Pressure area prevention

Discussion

The college wants a lot from the answer here.

One should intubate this patient. In the second part of this question, the college hectors those candidates who chickened out of intubation in the first part.

Thus:

Firstly, one should complete the primary survey;

specific features to look for would be

• hypotension
• bradycardia
• hypothermia
• sources of bleeding

A FAST scan should be performed, looking for intraabdominal haemorrhage.

After all of this is done, the patient should be intubated with inline stabilisation of the C-spine. Videolaryngoscopy is probably the best way of doing this, given the awkwardness of an immobilised neck. This early, it is still safe to use suxamethonium.

Once ventilation is established, the patient should be taken to the CT scanner and a full CT trauma series should be acquired. Specifically, the extent of the spinal injury should be established. With these findings it will be possible to have a meaningful neurosurgical opinion. An MRI in this setting is probably not going to be meaningful unless it directs the neurosurgical approach. It is of use in settings where bony injury is not apparent, and imaging of the cord itself is needed to determine the level at which decompression might be beneficial.

Once surgical management is agreed upon, one can settle down to managing the routine FASTHUG.

As for the steroids... a Cochrane review of methylprednisone seemed promising - if methylprednisone is started withn 8 hours of the injury, and continued for 24-48 hours- but more recently opinion has shifted away from steroids.

Shah, Rajiv R., and Samuel A. Tisherman. "Spinal cord injury." Imaging the ICU Patient. Springer London, 2014. 377-380.

Batchelor, Peter E., et al. "Meta-Analysis of Pre-Clinical Studies of Early Decompression in Acute Spinal Cord Injury: A Battle of Time and Pressure."PloS one 8.8 (2013): e72659.

Bracken, Michael B. "Steroids for acute spinal cord injury." Cochrane Database Syst Rev 1 (2012).

Hurlbert, R. John, et al. "Pharmacological therapy for acute spinal cord injury." Neurosurgery 72 (2013): 93-105.

College Answer

Paradoxical movement in this setting suggests paralysed intercostals and residual diaphragm function. This produces at least 30% loss of FVC and will mean a poor cough in a supine patient. If he is struggling to breathe, he has no hope of effectively coughing. If the candidate had intubated the patient in (a) that was OK. The waverers should put the tube in and explain their technique in detail. There is limited place for non-invasive ventilation in this setting.

Discussion

As the college points out, paradoxical movement here demonstrates that only the diaphragm is moving the lungs. This is bad.

Thus: the patient needs to be intubated.

• ensure the presence of skilled assistants and standby airway-skilled staff
• ensure the rapid sequence induction drugs are prepared and checked
• ensure the intubation equipment is prepared and checked, and that difficult intubation equipment is ready (videolaryngoscope, McCoy blade, bougie)
• Ensure a Plan B is available (LMA)
• Ensure inline stabilisation of the C-spine to prevent any further injury
• Consider decompressing the stomach with an NGT before the intubation attempt to reduce the risk of aspiration
• Intubate the patient with rapid sequence induction, using cricoid pressure

College Answer

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.

Discussion

This question would benefit from a systematic response.

Thus:

• Definitive airway/ventilation management
  • The patient may remain intubated.
  • If this patient has had a severe traumatic brain injury, a tracheostomy may be required. If the C-spine is unstable this is best performed surgically, rather than percutaneously.
• Definitive hemostasis
  • This should be achieved by surgical repair of fractures, wounds, and organ damage. External fixation of long bone fractures is a valid alternative.
    • Early repair of contaminated wounds or compound fractures
    • Delayed closure of laparotomy wounds
    • Vac-dressing for abdominal defects
• Definitive neurological/neurosurgical management
  • Neurosurgical intervention
  • Standard neuroprotective measures
  • Referral to brain injury rehabilitation

ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma

College Answer

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.

Discussion

This is a question about the initial blood workup and primary/secondary survey investigations.

Thus:

Bloods:

• FBC
• EUC
• CMP
• LFT
• Coags
• Crossmatch

Imaging

• Chest Xray
• FAST including pericardium
• Pelvic Xray
• Long bone Xrays
• CT trauma series including aortogram

Monitoring

• ECG
• Urine output
• Arterial invasive blood pressure
• ICP monitoring may be indicated if the intracranial pressure cannot be monitored clinically

ATLS student course manual, 8th edition (Chapter 5) - American College of Surgeons Committee on Trauma

College Answer

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.

Discussion

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:

• CXR
• Pelvic XR
• FAST US of the abdomen chest and praecordium can rapidly differentiate between the abovementioned causes of shock.
• CT trauma series, if available

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

College Answer

Tone may well still be decreased (though with time this will increase, with posturing developing in an  upper  motor  neurone  distribution).     Anal  tone  would  be  lax  with  a  complete  lesion. Quadriparesis would be expected, with no movement below deltoid.  Respiratory muscles may be significantly compromised.   Reflexes may still be absent, though with time will increase.   The plantar reflex should be upgoing.  A sensory level is expected between C2 to C6, and to all modalities (eg. touch, pain, temperature, JPS and vibration).

Discussion

This question  is identical to Question 14 from the second paper of 2005.

College Answer

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.

Discussion

This question about post-splenectomy ICU management  is identical to Question 13 from the second paper of 2005.

College Answer

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.

Discussion

This question is identical to Question 12 from the second paper of 2005.

College Answer

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.

Discussion

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:

• The airway is more difficult to control.
• There is an increased risk of aspiration
• The respiratory function is impaired by decreased FRC;
  • One needs to insert thei chest drains higher, so as to avoid the pushed-up diaphragms
• When setting up the ventilator, one needs to keep in mind that the PaCO₂ is supposed to be 30mmHg in late pregnancy.
• The total blood volume has expanded, the cardiac output is high, and thus signs of shock will develop late.
• Vena cava compression means the patient needs to be positioned at a 30° tilt
• Pelvic binders are inappropriate
• Pelvic fractures may threaten the near-term foetus
• Placental abruption may result in massive haemorrhage and needs to be excluded early in the primary survey
  • foetal heart rate monitoring is essential
• Retroperitoneal haemorrhage from dilated pelvic veins can be difficult to assess without ultrasound (but FAST is still effective)
• A vaginal examination needs to be performed, looking for amniotic fluid (a pH of 7.0-7.5 will confirm this - the normal vaginal pH is much lower than this)
• Rhesus-negative mothers need to receive IV immunoglobulin at least within 48 hours of the trauma
• Transfusion needs to be Rh compatible
• Antibiotic choices are limited; tetracyclines and fluoroquinolones are to be avoided
• The pregnant trauma patient is in an even more hypercoagulable state than the normal trauma patient, and thus requires special attention to DVT prophylaxis

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.

College Answer

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.

Discussion

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.

College Answer

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).

Discussion

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.

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.

College Answer

Management of patients with potential cervical spine injuries is still controversial, despite a number  of  major  groups  attempting to  provide  evidence  based  guidelines  (eg.  ATLS, Eastern Association for the Surgery of Trauma). Delayed clearance of the cervical spine can result in many potential problems, related to requirements for immobilisation as well as the cervical collar (eg. pressure areas, airway access, delayed mobilisation etc.).   Candidates often failed to discuss the “subsequent management” component.

Patients with major trauma are at increased risk of having associated spinal injuries (including those related to the cervical spine).  All patients should be treated as if they have cervical spine injuries (ie. appropriately immobilised) until further information is available. The conscious patient without distractors can be assessed and managed clinically (National Emergency  X-radiography Utilization  Study,  Hoffman  NEJM  2000),  but  the  scenario usually seen in ICU is one where one or more pre-conditions for clinical clearance are not met (eg. distracting injuries, or presence of intoxicants).   In this scenario the usual recommendation is three view cervical spine radiographs (AP, lateral and open mouth view) supplemented by high resolution CT (especially directed to suspicious areas).  Debate still surrounds the need for lateral fluoroscopic flexion/extension to decrease the injuries missed by plain films and CT (EAST J Trauma 1998, www.east.org, Morris BMJ 2004).

Routine MRI is problematic because of ferromagnetic compatibility.

Discussion

The issue of clearance of the C-spine in the unconscious patient is covered elsewhere. And in any case, that is not what the question is asking.

The key points the college wanted to see seem to have been pragmatic ones.

Some adjustments must be made to correct for the age of this question, and recent findings.

• All trauma patients to be treated as potential C-spine trauma
• C-spine collars and precautions should remain in situ until the C-spine is cleared
• The C-spine in conscious patients should be cleared according to the NEXUS criteria
• In unconscious patients, a normal CT excludes an overwjhelming majority of clinically significant ligamentous and bony injuries
• Plain radiographs and flexion-extension views are no longer recommended
• Routine MRI is not recommended
• C-spine clearance should be prompt as there is a significant risk from pressure areas and increased intracranial pressure.

Thus, "subsequent management" should include the following:

• Attention to pressure area care
• Immobilisation of the C-spine for airway manipulation and patient mobility
• Conversion to a comfortable collar
• Attention to central venous access
• Monitoring of ICP

The Alfred Spinal Clearance Protocol

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.

College Answer

Tone: Tone may well still be decreased (though with time this will increase, with posturing developing in an upper motor neurone distribution: some flexion of upper limb if incomplete level to C6). Anal tone would be lax with a complete lesion.

Power: Quadriparesis would be expected, with no movement below deltoid. Respiratory muscles may be significantly compromised.

Reflexes: Reflexes may still be absent, though with time will increase. The plantar reflex should be upgoing.

Sensation: A sensory level is expected between C2 to C6, to all modalities (eg. touch, pain, temperature, joint position sense and vibration).

Other signs: Warm vasodilated peripheries, Skin venodilation , Priapism, Hypotension, Bradycardia, Tendency to Hypothermia, Rocker-boat respiratory pattern (with increased use of respiratory accessory muscles, and absent intercostals).

Discussion

A C4 lesion should produce the following features:

• Incomplete diaphragm paralysis, purely diaphragmatic breathing pattern
• Complete motor paralysis of all 4 limbs
• Complete sensory loss in whole body below the C4 sensory level (shoulder)
• Cardiovascular instability: bradycardia and hypotension
• Acute gastric dilatation and paralytic ileus
• Priapism
• Urinary retention
• Loss of bowel continence
• Horner's syndrome

Physiological consequences of spinal cord transection are well discussed elsewhere.

The Spinal Cord Medicine Clinical Practice Guidelines series (provided by Paralysed Veterans of America) has a nice brochure of what one is to expect with a C4 injury.

College Answer

Jefferson fracture:  burst fracture of the atlas (C1); usually combined anterior and posterior arch fractures; results from axial compression of C1 in circumstances such as diving into water head first or being thrown against the roof of a car or aircraft; may also result from hyperextension causing a posterior arch fracture. Unstable.

Hangman’s fracture:  bilateral fracture of the posterior arch of C2 and disruption of the C2-3 junction;  neurological  injury  may  result  from  damage  to  the  posterior  longitudinal  ligament allowing significant anterior displacement of C2 on C3; results from C-spine hyperextension with vertical  compression  of  the  posterior  column  eg.  a  car  accident  victim’s  head  striking  the dashboard. Unstable.

Clay-shoveller’s fracture: fracture of one or more of the spinous processes of the C6-T3 vertebra; it is an avulsion fracture by the supraspinous ligament of the spinous process caused hyperflexion. Stable.

Discussion

The first two are unstable, and the last one is stable.

Observe:

Thompson, Wendy L., et al. "Association of injury mechanism with the risk of cervical spine fractures." CJEM 11.1 (2009): 14-22.

Pimentel, Laura, and Laura Diegelmann. "Evaluation and management of acute cervical spine trauma." Emergency medicine clinics of North America 28.4 (2010): 719-738.

College Answer

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. 

Discussion

This patient has four major issues:

• Potential high spinal injury
• Lower left chest injuries
• Features of shock, which may be haemorrhagic or spinal
• A painful distending abdomen, which may be due to solid organ trauma.

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:

• Left haemothorax
• Abdominal haematoma due to splenic injury
• Cardiac tamponade
• High spinal cord section

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:

• CXR
• Pelvic XR
• FAST US of the abdomen chest and praecordium can rapidly differentiate between the abovementioned causes of shock.
• CT trauma series, if available

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

College Answer

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.

Discussion

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:

• Coags, troponin, CK, EUC FBC and LFTs
• ECG
• Repeat CXR
• Xrays of the long bones
• CT trauma series, including fine slice through the C spine

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.

College Answer

The likely complications are multiple. One approach is to divide them according to acute
respiratory, acute cardiovascular, other acute issues, and subacute/chronic complications:

Acute Respiratory complications
•    Respiratory failure: Lesions above C3 result in respiratory arrest; Lesions above C5 can still result in respiratory failure; Increased likelihood with VC < 15ml/kg, work of breathing, hypoxia, coexisting head or other injuries
•    Poor cough with difficulty with clearance of secretions
•    Atelectasis
•    Pulmonary oedema due to cardiac failure, over vigorous fluid management ARDS (numerous causes) or neurogenic pulmonary oedema

Acute Cardiovascular complications
•    Sympathetic denervation of the heart (with bradycardia, decreased inotropy) and peripheral vasculature (vasodilation)
•    Hypotension from above causes
•    Tendency to cardiac failure with overvigorous fluid management, especially if cardiac sympathetics lost

Other Acute issues
•    Deep Vein Thrombosis & Pulmonary embolism (4- 10% without prophylaxis)
•    Bowel denervation – paralytic ileus and gastroparesis
•    Bladder denervation – urinary retention with increased risk of urinary tract infection
•    Abnormal temperature regulation

Subacute and Chronic issues
•    Pressure areas – loss of mobility and sensation
•    Risk of sepsis – Pulmonary, UTI, Pressure areas and occult peritoneal infection
•    Autonomic hyperreflexia – 70 – 90% patients with lesion above T7
•    Hyperkalaemia with suxamethonium – especially after 24 hours
•    Psychological

Discussion

The early and late complications of spinal cord injury are discussed in greater detail in chapters dedicated to that topic:

• Physiological consequences of spinal cord transection
• Management of acute high spinal injury
• Important spinal cord injury syndromes

Of the college answer, the issues which this table does not touch upon are those which are generic to immobility, and therefore boring. We are of course talking about pressure areas, DVTs, psychological morbidity, et cetera.

Baydur, Ahmet, Rodney H. Adkins, and Joseph Milic-Emili. "Lung mechanics in individuals with spinal cord injury: effects of injury level and posture." Journal of applied Physiology 90.2 (2001): 405-411.

Teasell, Robert W., et al. "Cardiovascular consequences of loss of supraspinal control of the sympathetic nervous system after spinal cord injury." Archives of physical medicine and rehabilitation 81.4 (2000): 506-516.

College Answer

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.

Discussion

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

• Confusion is usually the earliest symptom
• Dyspnoea
• Tachypnoea
• Haemoptysis
• Usually, with a latent period (say, some days after the manipulation of a fracture).

Signs of fat embolism

• • Respiratory features: moist crepitations over all lung fields, hypoxia, cyanosis
  • Characteristic petechial rash, usually over the anterior axillary fold and at the root of the neck, as well as on the buccal mucosa and the conjunctiva. This distribution can be explained by fat droplets accumulating in the aortic arch prior to embolisation to nondependent skin via the subclavian and carotid vessels.

• • Fever
  • Tachycarda
  • Retinal haemorrhages
  • Visible fat droplets on ophthalmoscopy
  • Jaundice
  • Renal impairment
  • Anaesthetists often note a sudden drop in end-tidal CO₂ concentration during a stable steady state.

Laboratory features

• • Thrombocytopenia
  • Anaemia (sudden decrease)
  • High ESR
  • Fat macroglobulinaemia

Causes of fat embolism

• • Long bone fractures
  • Liposuction
  • Bone marrow harvest
  • Lymphography
  • Acute pancreatitis
  • Necrosis of a fatty liver
  • Acute sickle cell crisis (with marrow necrosis)

Management of fat embolism

• Boring, non-specific treatment:
  • O₂ supplementation
  • Positive pressure ventilation
  • Correction of coagulopathy
  • Replacement of platelets
  • Correction of the source problem (i.e. reduction of fractures)

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.

College Answer

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

Discussion

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:

• Airway issues
  • The airway is more difficult to control.
  • There is an increased risk of aspiration due to decreased gastric emptying and weakened lower oesophageal sphincter.
• Respiratory issues
  • The respiratory function is impaired by decreased FRC;
  • One needs to insert their chest drains higher, so as to avoid the pushed-up diaphragms
  • When setting up the ventilator, one needs to keep in mind that the PaCO₂ is supposed to be 30mmHg in late pregnancy.
• Circulatory issues
  • The total blood volume has expanded, the cardiac output is high, and thus signs of shock will develop late.
  • Vena cava compression means the patient needs to be positioned at a 30° tilt
• Neonatal and foetal welfare
  • Pelvic binders are inappropriate
  • Pelvic fractures may threaten the near-term foetus
  • Placental abruption may result in massive haemorrhage and needs to be excluded early in the primary survey
  • Foetal heart rate monitoring is essential
  • Early transfer to an O&G-equipped hospital is essential
  • Retroperitoneal haemorrhage from dilated pelvic veins can be difficult to assess without ultrasound
  • A vaginal examination needs to be performed, looking for amniotic fluid (a pH of 7.0-7.5 will confirm this - the normal vaginal pH is much lower than this)
• Transfusion and general haematology issues
  • Rhesus-negative mothers need to receive IV immunoglobulin at least within 48 hours of the trauma
  • Transfusion needs to be Rh compatible
  • The pregnant trauma patient is in an even more hypercoagulable state than the normal trauma patient, and thus requires special attention to DVT prophylaxis
• Drug choices
  • Antibiotic choices are limited; tetracyclines and fluoroquinolones are to be avoided
  • If urgent caesarian delivery is planned, intubation drugs wil affect the foetus; thus there is need for NICU involvement for ventilation

Issues to consider in investigations and the secondary survey

• 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.

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.

College Answer

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.

Discussion

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:

• CSF otorrhoea
• Haemotympanum
• Racoon eyes (adults call it "bilateral periorbital haematoma")
• CSF rhinorrhoea
• Cranial nerve abnormalities:
  • CNI damage (loss of olfaction)
  • CN II entrapment (visual field defects or blindness)
  • CN VII palsy (facial paralysis)
  • CN VIII palsy (deafness)
• Blephaerohaematoma (i.e. of the eyelid)
• Pneumoencephalus (more of a radiological finding)
• Bloody otorrhoea
• CSF otorrhoea

Complications of a base of skull fracture include the following:

• Meningitis/encephalitis
• Carotid artery dissection
• Cavernous sinus thrombosis
• Pneumocephalus due to positive pressure ventilation
• Accidental cannulation of the cranial cavity with the nasogastric tube
• Carotido-cavernous fistula
• CSF fistula

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).

College Answer

This is a controversial area with no consensus. Aim is to test understanding of literature on cervical spine injury, sensitivity and limitations of imaging, risk Vs benefits, understanding of institutional protocols and systems issues. A well reasoned and an appropriate approach would score high marks. 

A suggested  approach is

1.   Detailed history and clinical exam with review of mechanism of injury, speed, other injuries

2.   3 view (AP, lateral and peg view) or 5 view( 3 + right and left obliques) cervical spine  with focussed CT to missed areas or CT scan of neck from base of skull to upper thoracic vertebrae with reconstructions.

3.   If CT scan normal after interpretation by specialist radiologist and ortho spine/neurosurgeon/ICU specialist then neck is “clear”.

4.   MRI if clinically suspected spinal neurological injury or abnormal CT scan or very high risk cord injury ( high speed, ejection from vehicle, high ISS)

5.   Transfer to specialised trauma centre.

Justification

1.   5-10 % of patients with a severe head injury have an associated unstable cervical fracture.

2.   Clinical clearance not possible here.

3.   Maintaining cervical/spinal  immobility via a cervical collar until clinical clearance increases the risk of pressure areas,  pneumonia and raised intracranial pressure.

4.   3 and 5 view cervical X rays are frequently of inadequate quality and detect 75-
90% of unstable injuries even when of adequate quality and correctly interpreted.

5.   Multislice CT scan from the base of skull to upper thoracic spine with sagittal and coronal reconstructions will detect most injuries.  It may miss an unstable ligamentous injury without bone fracture (risk 1/1000). It is convenient to image the neck at the same time as the CT brain scan or other CT scans

6.   MRI will detect spinal cord and soft tissue pathology such as ligamentous injury, spinal cord injury and epidural haematoma.

Additional Marks:
•    Role of flexion extension views
•    Requirements for clinical clearance
•    Timing of clearing cervical spine Vs attending to other life threatening injuries
•    Institutional Protocols

Discussion

Details regarding the clearance of the C-spine in the unconscious patient are discussed elsewhere.The rules seem to have changed somewhat since this answer was written, and these days we dont tend to ask for flexion-extsnion views and lateral C-spine Xrays very often.

In short, the algorithm one should follow ought to resemble the excellent Alfred algorithm, which incorporates evidence from the post-CT era. Remember that many of the early studies were done on CT scanners with 2.5mm slices, or thicker - these days the resolution is substantially better than that.

• If the patient is unconscious and the C-spine cannot be cleared by the NEXUS criteria, the patient should have full spinal precautions.
• A CT of the C-spine should be performed as soon as the process of trauma resuscitation permits- ideally, as a part of a CT trauma series.
• A CT will miss a few ligamentous injuries, but very few of these are clinically significant.
• If the CT is normal (and senior radiology or neurosurgical staff agree that it is normal), the collar can be taken off. However, if the mechanism of injury strongly favours C-spine trauma, one may choose to perform an MRI anyway.
• One should ignore the normal CT if there is evidence of spinal cord injury (eg. focal neurological signs unexplained by the head injury) or if the mechanism suggests that such an injury might be present.
• One should perform an MRI wherever there is CT abnormality suggestive of ligamentous injury. One should guard against misinterpreting the medicolegally defensive wording of the CT reports, which inevitably whinge that "ligamentous injury cannot be excluded".
• Wherever CT and MRI are available, one should never agion order flexion-extension views, as they are essentially useless and add nothing.

The Alfred Spinal Clearance Protocol

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.

College Answer

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)

Discussion

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:

• Rapid termination of an operation after control of life-threatening bleeding and contamination followed by correction of physiologic abnormalities and definitive management.

Rationale:

• Hypothermia, acidosis, and coagulopathy render attempts at definitive surgical repair less likely to succeed.
• The surgical control of immediately lifethreatening injuries and the establishment of haemostasis must be achieved early, but definitive management can be delayed in most cases.
• Definitive management can take place safely once the physiological abnormalities are corrected.

Key principles:

• Control of haemorrhage
• Control of contamination
• Use of temporary shunts to bypass ligated vascular injuries
• Delay of abdominal closure, or temporary wound closure

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:

• Old, uncontrolled traumatic bleeding
• New, uncontrolled surgical bleeding
• Uncontrolled coagulopathy, hypothermia and acidosis
• An open abdomen (thus, high sedation and analgesia requirements)
• Abdominal compartment syndrome (if they decided to close it)
• Missed injuries

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.

College Answer

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.

Discussion

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:

• Hypoxia
• Decreased air entry on the affected side
• Decreased chest excursion on the affected side
• Dull percussion note
• Bowel sounds in the chest
• Ileus and bowel obstruction due to volvulus
• Shoulder pain
• Stool or bile in the chest drain

As for the rectal examination; one looks for

• Sphincter tone (cord injury)
• Gross blood (GI tract injury)
• Swelling (pelvic haematoma)
• "High riding" prostate - urethral injury
• Mobile coccyx- sacral or coccygeal fracture
• Obvious external anal damage
• Disrupted rectal wall integrity

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.

College Answer

1. Raccon eyes
2. Battle’s sign
3. CSf rhinorrhoea
4. CSF otorrhoea
5. Hemotympanum
6. Lower cranial nerve palsies

Discussion

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.

College Answer

Discussion

This answer is mirrored by the discussion of spinal cord syndromes,which takes place elsewhere.

In brief:

Wagner, Robert, and Andy Jagoda. "Spinal cord syndromes." Emergency medicine clinics of North America 15.3 (1997): 699-711.

Lin, Vernon W., et al. "Spinal Cord and Cauda Equina Syndromes." (2003).

Maynard, Frederick M., et al. "International standards for neurological and functional classification of spinal cord injury." Spinal cord 35.5 (1997): 266-274.

College Answer

Metabolic 
Hyponatremia (SIADH)
Immobilisation hypercalcemia and nitrogen wasting

Hypothermia

GI 
Ileus 
acute gastric dilatation

stress ulcerations

Discussion

This question only has room enough for a few minutes of thought. It is, after all, only the third part of a multi-part question. And one could spend an excessively long time discussing the various physiological disturbances which occur in response to spinal cord injury.

Metabolic

Hyponatremia (SIADH) - due to spinal hypotension
Immobilisation hypercalcemia - due to mysterious mechanisms, likely associted with the loss of mechanical loading of bones (which is normally a trophic stimulus)

Nitrogen wasting - Again, the loss of trophic stimulus results in muscle wasting and increased protein catabolism .

Hypothermia - largely due to the loss of sympathetic control (i.e. the inability to correctly specify when one's cutaneous vessels dilate or constrict).

The original version of this question for some reason had "nitrogen wasting hypothermia" as a college answer, but as a kind reader has pointed out the college never had this weird combination of words in their paper. It makes no sense, and it seems nowhere else in the world do these words occur in this exact combination. (if you google it, the only answers you get are from sites which directly quote the CICM paper).

Gastrointestinal

Ileus due to loss of autonomic control.
Acute gastric dilatation due to the "body cast syndrome", compression of the duodenum between the aorta and the superior mesentric artery.

Stress ulcerations due to unopposed vagal stimulus of the acid-secreting parietal cells.

Physiological consequences of spinal cord transection are discussed in detail elsewhere.

Claus-Walker, J., and L. S. Halstead. "Metabolic and endocrine changes in spinal cord injury: I. The nervous system before and after transection of the spinal cord." Archives of physical medicine and rehabilitation 62.12 (1981): 595-601.

Claus-Walker, J., and L. S. Halstead. "Metabolic and endocrine changes in spinal cord injury: II (section 1). Consequences of partial decentralization of the autonomic nervous system." Archives of physical medicine and rehabilitation63.11 (1982): 569-575.

Claus-Walker, J., and L. S. Halstead. "Metabolic and endocrine changes in spinal cord injury: II (section 2). Partial decentralization of the autonomic nervous system." Archives of physical medicine and rehabilitation 63.11 (1982): 576-580.

Claus-Walker, J., and L. S. Halstead. "Metabolic and endocrine changes in spinal cord injury: III. Less quanta of sensory input plus bedrest and illness."Archives of physical medicine and rehabilitation 63.12 (1982): 628-631.

Claus-Walker, J., and L. S. Halstead. "Metabolic and endocrine changes in spinal cord injury: IV. Compounded neurologic dysfunctions." Archives of physical medicine and rehabilitation 63.12 (1982): 632-638.

GORE, RICHARD M., RICHARD A. MINTZER, and LEONID CALENOFF. "Gastrointestinal complications of spinal cord injury." Spine 6.6 (1981): 538-544.

Ebert, Ellen. "Gastrointestinal involvement in spinal cord injury: a clinical perspective." Journal of Gastrointestinal & Liver Diseases 21.1 (2012).

Lin, Vernon W., et al. "Temperature Regulation in Spinal Cord Disease." (2003). Spinal Cord Medicine: Principles and Practice. Demos Medical Publishing, Inc.

College Answer

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

Discussion

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:

• CSF otorrhoea
• Haemotympanum
• Racoon eyes (adults call it "bilateral periorbital haematoma")
• CSF rhinorrhoea
• Cranial nerve abnormalities:
  • CNI damage (loss of olfaction)
  • CN II entrapment (visual field defects or blindness)
  • CN VII palsy (facial paralysis)
  • CN VIII palsy (deafness)
• Blephaerohaematoma (i.e. of the eyelid)
• Pneumoencephalus (more of a radiological finding)
• Bloody otorrhoea
• CSF otorrhoea

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.

College Answer

 “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.

Discussion

Permissive hypotension

Definition:

• Allowing a subnormal MAP in a trauma patient;
• " The strategic decision to delay the initiation of fluid resuscitation and limit the volume of resuscitation fluids/blood products administered to the bleeding trauma patient by targeting a lower than normal blood pressure, usually a systolic blood pressure of 80–90 mmHg or a mean arterial pressure (MAP) of 50 mmHg" - Kaafarani et al, 2014

Rationale:

• In penetrating trauma, a lower MAP may improve hemostasis.
• Improved hemostasis may result in smaller transfusions, decreased coagulopathy, and less transfusion-associated adverse events

Key principles:

• Goal is hemostasis, rather than the actual low blood pressure
• MAP of 50 appears to be associated with decreased transfusion requirements but not increased adverse events

Haemostatic resuscitation

Definition:

• Rapid correction of hemostasis-impairing factors, such as hypothermia hypocalcemia and acidosis
• Resuscitation with a balanced combination of blood products, which in combination resemble the composition of whole blood, aiming to avoid dilutional coagulopathy.

Rationale:

• Unbalanced transfusion strategies lead to depletion of coagulation factors and exacerbation of dilutional coagulopathy.

Key principles:

• Early and aggressive transfusion of blood products aiming for a ratio of PRBCs, FFP, and platelets that approximates 1:1:1
• Use of hemostatic agents such as tranexamic acid (strongly supported by evidence)

Damage control surgery

An excellent article on this is available from 2004 (Critical Care Clinics)

Definition:

• Rapid termination of an operation after control of life-threatening bleeding and contamination followed by correction of physiologic abnormalities and definitive management.

Rationale:

• Hypothermia, acidosis, and coagulopathy render attempts at definitive surgical repair less likely to succeed.
• The surgical control of immediately lifethreatening injuries and the establishment of haemostasis must be achieved early, but definitive management can be delayed in most cases.
• Definitive management can take place safely once the physiological abnormalities are corrected.

Key principles:

• Control of haemorrhage
• Control of contamination
• Use of temporary shunts to bypass ligated vascular injuries
• Delay of abdominal closure, or temporary wound closure

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.

College Answer

a)

The patient is sedated and so the spine cannot be cleared clinically so will keep collar in place. Also check correct size and fitting. Firstly clear radiologically – review all images and obtain formal radiologist reports. Trauma series (typically only CXR and pelvic XR as C-spine films are low yield and no longer suggested as a routine) looking for obvious vertebral fractures +/- dislocations as patients with a fracture on CXR or PXR have higher risk of C-spine fracture.

High resolution 64 slice helical CT of the entire cervical spine and T1 with sagittal and coronal

reconstructions - With technically adequate studies and experienced interpretation, the combination of multi-slice helical CT with reconstruction CT scanning provides a false negative rate of < 0.1%

Clear radiologically and if low risk for ligamentous injury and patient unlikely to be extubated in 24-48 hr, remove collar.

Or: If no bony injury but need to exclude ligamentous injury, perform MRI.

Or: If bony injury present assessment for instability and surgery and immobilization as indicated in discussion with spinal surgeons.

b)

• Prolonged immobilization is associated with significant morbidity
• Decubitus ulceration (especially related to cervical collar)
• Increased need for sedation
• Delayed weaning from respiratory support
• Delays in percutaneous tracheostomy
• Central venous access difficulties
• Enteral feeding intolerance due to supine positioning
• Pulmonary aspiration due to supine positioning
• DVT due to prolongation of immobility
• Increased risk of cross-infection due to extra staff / equipment involved in position changes

Discussion

The college answer is written strangely. I have written my own answer... It may not be any better. It answers the question "how do you clear the C-spine of an non-communicative patient"

• Maintain spinal precautions and keep collar on, ensuring it is properly fitted.
• Seek to clear the C-spine within 72 hours
• Perform helical CT of C-spine with multiplanar reconstructions
• Solicit an expert radiologist report on the helical CT
• If radiologically there is bony injury, the collar stays on and a neurosurgical referral is made
• If radiologically there is no bony injury but suspicion of ligamentous injury is raised by abnormal CT findings,
  • An MRI of the C-spine is performed
  • An expert radiologist opinion is sought regarding the possibility of ligamentous injury
    • If the MRI confirms ligamentous injury, the collar stays on and a neurosurgical referral is made
    • Otherwise, the MRI clears the C-spine and the collar may be removed
• If radiologically there is no bony injuries nor suspicion of ligamentous injury,
  • And extubation is not planned in the next 48 hours,
    • Then the collar may be removed.
  • If extubation is planned in the next 48 hours,
    • Consider leaving collar in situ and clearing the C-spine clinically once the patient is alert and cooperative, provided there are no distracting injuries.

The best resource I have found as a complete C-spine clearance protocol was the 2006 publication from the Alfred in Melbourne.  Why was it the best?  Well. Firstly, it's on the health.gov.au website, so its local policy. Secondly, its based on international published data, and is well-referenced.  Lastly, the college answer for question 4(b) was cut and pasted verbatim from the Alfred protocol, page 5.

As for problems with being in a hard collar, here is a list of problems from  a 2004 review by Morris and McCoy (quoted in Oh's Manual).

Problems associated with prolonged C-spine immobilisation

• Pressure areas under the collar
  • Source of sepsis
  • Need for skin grafts
  • Increased hospital stay
• Increased intracranial pressure
• Airway is made more difficult by in-line stabilisation
• Central venous access is made more difficult (IJ is out of bounds)
• Oral care is made more difficult, increasing the risk of VAP
• Nutrition is affected:
  • Gastroparesis and ileus results from prolonged immobility
  • Aspiration risk is increased by supine position
• Physiotherapy is delayed or impossible
• A greater risk of DVT/PE results from prolonged immobility
• A minimum of 4 nursing staff are required to turn the patient.

Brohi K, Healy M, Fotheringham T, Chan O, Aylwin C, Whitley S, Walsh M. Helical computed tomographic scanning for the evaluation of the cervical spine in the unconscious, intubated trauma patient. J Trauma. 2005 May;58(5):897-901.

Ackland, HM. The Alfred Spinal Clearance Management Protocol. 2006. The Alfred Hospital, Melbourne, Australia.

Chiu, William C. MD; Haan, James M. MD; Cushing, Brad M. MD; Kramer, Mary E. RN, and; Scalea, Thomas M. MD Ligamentous Injuries of the Cervical Spine in Unreliable Blunt Trauma Patients: Incidence, Evaluation, and Outcome Journal of Trauma-Injury Infection & Critical Care: March 2001 - Volume 50 - Issue 3 - pp 457-464

J L Harrison, BA (Hons)1 and  S J Ostlere, FRCP, FRCR2 Diagnosing purely ligamentous injuries of the cervical spine in the unconscious trauma patient British Journal of Radiology (2004) 77, 276-278

College Answer

a)  What clinical sign is illustrated in this picture?

Conjunctival petechiae

b)  What is the likely cause of the respiratory failure?

Fat embolism syndrome

Discussion

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.

College Answer

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.

Discussion

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.

College Answer

a) List the likely causes of this man's shock state.

• Hypovolaemia
  • Ongoing blood loss related to trauma including missed injuries
  • Ongoing blood loss related to the emergency splenectomy
  • Under-resuscitation prior to ICU admission
• Cardiogenic causes
  • Cardiac contusion
  • Myocardial ischaemia with pre-existing heart disease
  • Primary arrhythmia unlikely cause as rate only 140
• Obstructive causes
  • Cardiac tamponade
  • Tension pneumothorax
  • Fat embolism syndrome (less likely with compound tibial fracture)
  • PE (less likely in acute stage)
• Distributive shock states (sepsis, spinal) and anaphylaxis unlikely with cold peripheries

b) List the clinical features that would help distinguish between these likely causes

• Hypovolaemia (ongoing bleeding / under-resuscitation)
  • Jugular venous pressure not visible
  • Positive response to passive leg raise
• Cardiac tamponade
  • Evidence of pulsus paradoxus upon auscultation in determining blood pressure
  • Raised jugular venous pressure upon inspiration (Kussmaul's sign)
  • Muffled heart sounds
• Cardiac contusion
  • Evidence of heart failure (raised jugular venous pressure, fine inspiratory crackles) 25
• Tension pneumothorax
  • Surgical emphysema
  • Tracheal deviation away from side of pneumothorax
  • Quiet breath sounds on side of side of pneumothorax

c) What echocardiographic features are associated with the causes you have described?

• Hypovolaemia
  • Reduced left ventricle end diastolic area
  • LV end systolic cavity obliteration
  • Reduced inferior vena cava diameter with pulse variation
• Cardiac tamponade
  • Right atrial systolic collapse and right ventricular diastolic collapse
  • Increased pericardial fluid
  • Swinging heart
  • Dilated IVC
• Cardiac contusion
  • Regional wall motion abnormalities
• Tension pneumothorax
  • Reduced left ventricle end diastolic area
  • Distended superior vena cavae

Discussion

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.

College Answer

Life-threatening situation and management involves a multi-disciplinary approach following EMST guidelines.

• Obtain large-bore IV access (2 x 14G IV cannulae in ACFs) and send blood for cross-match and appropriate investigation

• Resuscitation fluids – crystalloid / colloid / blood (group specific or cross-matched dependent on urgency) administered to resuscitation end-points (MAP 60-70) in ratio of packed cells to FFP and platelets 1:1

• Avoid excessive movement of the pelvis and stabilize with sheet or commercial external pelvic stabilizer device

• CXR and secondary survey to look for other sources of bleeding

• Investigate for associated intra-abdominal or intra-pelvic injuries with FAST scan and/or CT scan if patient has stabilized with resuscitation

• Urgent consultation with interventional radiologist for angiography and embolization if other sources of bleeding excluded and if interventional radiology service available

• Urgent consultation with orthopaedic surgeon for external fixation

• Urgent consultation with general surgeon if intra-abdominal blood or evidence of intestinal perforation

• Aortic balloon occlusion also described as temporizing measure for patients in extremis from pelvic bleeding

• Analgesia

• Antibiotics if suspected / proven disruption of bowel or urinary tract

Discussion

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

• Blood product replacement to ensure normal coagulation function
• Pelvic binder
• Tranexamic acid and/or Factor VIIa
• Direct external compression of the aorta
• Intra-aortic balloon occlusion
• Reduction of acetabular fracture by lower limb traction
• Angioembolisation by interventional radiologist
• Surgical exploration / external fixation

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).

College Answer

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

Discussion

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:

• Airway issues
  • The airway is more difficult to control.
  • There is an increased risk of aspiration due to decreased gastric emptying and weakened lower oesophageal sphincter.
• Respiratory issues
  • The respiratory function is impaired by decreased FRC;
  • One needs to insert their chest drains higher, so as to avoid the pushed-up diaphragms
  • When setting up the ventilator, one needs to keep in mind that the PaCO₂ is supposed to be 30mmHg in late pregnancy.
• Circulatory issues
  • The total blood volume has expanded, the cardiac output is high, and thus signs of shock will develop late.
  • Vena cava compression means the patient needs to be positioned at a 30° tilt
• Neonatal and foetal welfare
  • Pelvic binders are inappropriate
  • Pelvic fractures may threaten the near-term foetus
  • Placental abruption may result in massive haemorrhage and needs to be excluded early in the primary survey
  • Foetal heart rate monitoring is essential
  • Early transfer to an O&G-equipped hospital is essential
  • Retroperitoneal haemorrhage from dilated pelvic veins can be difficult to assess without ultrasound
  • A vaginal examination needs to be performed, looking for amniotic fluid (a pH of 7.0-7.5 will confirm this - the normal vaginal pH is much lower than this)
• Transfusion and general haematology issues
  • Rhesus-negative mothers need to receive IV immunoglobulin at least within 48 hours of the trauma
  • Transfusion needs to be Rh compatible
  • The pregnant trauma patient is in an even more hypercoagulable state than the normal trauma patient, and thus requires special attention to DVT prophylaxis
• Drug choices
  • Antibiotic choices are limited; tetracyclines and fluoroquinolones are to be avoided
  • If urgent caesarian delivery is planned, intubation drugs wil affect the foetus; thus there is need for NICU involvement for ventilation

Issues to consider in investigations and the secondary survey

• 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.

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.

College Answer

• The patient is sedated and so the cervical spine cannot be cleared clinically so will keep collar in place. Also check correct size and fitting.

• • Radiological clearance

• • Plain C-spine films are no longer suggested as routine part of trauma series but fractures on CXR and pelvic XR associated with increased risk of C-spine injury

• • High resolution 64 slice helical CT of the entire cervical spine and T1 with sagittal and coronal reconstructions
  • Review with radiologist

• • With technically adequate studies and experienced interpretation, the combination of multi-slice helical CT with reconstruction CT scanning provides a false negative rate of < 0.1%

• • Clear radiologically and if low risk for ligamentous injury and patient unlikely to be extubated in 24-48 hr., remove collar.

Or:

If no bony injury but need to exclude ligamentous injury, perform MRI.

There is no 100% accurate method to exclude C-spine injury and management is a balance of risk-benefit for that individual. In some cases clearing the C-spine early may not be possible and leaving the collar in situ is a balance between management of potentially “unstable” C-spine and the risk of complications from the collar.

b)

• Prolonged immobilization is associated with significant morbidity
• Decubitus ulceration (especially related to cervical collar)
• Increased need for sedation
• Delayed weaning from respiratory support
• Delays in percutaneous tracheostomy
• Central venous access difficulties
• Enteral feeding intolerance due to supine positioning
• Pulmonary aspiration due to supine positioning
• DVT due to prolongation of immobility
• Increased risk of cross-infection due to extra staff / equipment involved in position

Discussion

This question closely resembles Question 4 from the second paper of 2011.

College Answer

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.

Discussion

Change in the pattern of injuries associated with morbid obesity

• Injury scores are lower in obese patients (Arbabi et al, 2003)
• Pattern of blunt trauma is different (Boulanger et al, 1992)
  • Injuries that are more likely:
    • pulmonary contusion
    • rib fractures
    • pelvic injuries
    • kneedislocations (Fuchs et al, 2014)
    • extremity fractures
    • proximal upper extremities seem to get it worst (Evans et al, 2011)
  • Injuries that are less likely:
    • head injuries
    • liver injuries
• "Obese people injured in vehicular crashes had a similar injury pattern with no difference in seating position, direction of impact, seat belt use, and ejection."

Influence of morbid obesity on the primary and secondary survey

1. - Difficult airway; difficult bag-mask ventilation more likely than actual difficult intubation.
   - Short handle may be required for direct laryngoscopy; most people would just resort to the videolaryngoscope.
   - When intubating, the FRC is small and the patient will become hypoxic rapidly, which means fewer attempts will be possible.
   - Increased risk of obstruction, even when awake
   - When obtunded, a virtual certainty of obstruction
    
2. - Poor chest wall compliance
   - Increased risk of atelectasis
   - Obesity hypoventilation syndrome
   - Difficult access for chest drains
   - Difficult windows for trauma TTE
   - Difficult auscultation and percussion, eg. for pneumothorax
   - Increased aspiration risk
    
3. - Difficulty measuring accurate blood pressure (need for appropriate size cuff)
   - Realistic possibility that no cuff will be appropriate and arterial access may be required
   - Difficult IV access- CVC as well as PIVC; the college answer recommends to go straight for the intraosseous needle
   - Intraosseous access is hardly fool-proof and can also be frustrated by obesity, considering especially the likelihood of there being bilateral knee prostheses
   - Possibility of pulmonary hypertension, cor pulmonale or CCF makes haemodynamic management more complex
    
4. - Likely, CO₂ retention and narcosis (influences doses of induction drugs)
   - Medullary sensitivity to CO₂ will be even more reduced by opiates
   - Some sort of syndromic condition may complicate neurological assessment (eg. Prader Willi syndrome)
    
5. - Log rolling will require additional assistants, or some sort of unusual equipment.

Influence of morbid obesity of FAST assessment

• Morbid obesity is one of the limitations of FAST
• Difficult insonation of the appropriate spaces; image quality is likely to be poor
• Pericardial fat can be misinterpreted as clotted blood
• Perinephric fat may be misinterpreted as intraperitoneal free fluid
• The advantage is, if you can't fit into the CT scanner this is all you've got.

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.

College Answer

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.

Discussion

Positioning for head injury

• Ideally, head up 45 degrees. At least angle the bed.
• It seems to position the patient at least 30° head up decreases the ICP but does not decrease the CPP.
• At least in the pediatric population, the angle of the bed is directly related to intracranial pressure.
• Ideally, the C-spine collar should be removed. A good study of intracranial pressure with and without the rigid collar found that one can decrease the intracranial pressure of a TBI patient by about 4-5mmHg simply by removing the rigid collar and using something like sandbags to stabilise the neck.
• The risk of head-up positioning may be haemodynamic instability, particularly if the sympathetic nervous system is not working (eg. severe diabetes, Parkinson disease or spinal injury)

Positioning for C-spine injury

• Hard collar is required if an injury is confirmed or suspected.
• The patient must lie flat, and be log-rolled.
• Clearance of the C-spine should occur as soon as it is practical
• There are many problems with wearing a collar for a prolonged period (eg. pressure areas, increased ICP, and so forth)

Positioning for T/L spine injuries

• The patient must lie flat, and be log-rolled.
• No bending is permitted
• The risk of such flatness is an increased incidence of VAP

Positioning for severe chest injuries

• Sit them up at least 30° if the head permits
• Do not lie them with the flail segment down. That lung has probably had a contusion anyway. Lie them "good lung down" - oxygenation will improve.
• Gentle lateral rotation may be appropriate
• Low-air-loss technology: specialist beds which turn the patient by inflating and deflating air cushions; a turning arc of 40-90° is possible.
• These are soft beds, unsuited for unstable spinal or pelvic injuries

Positioning in pelvic fractures

• The unstable pelvis must be in a binder
• Overmuch manipulation will result in haemodynamic instability
• Predictably, the solution is to fix the pelvis; angioembolisation may not be possible because the bleeding is frequently venous.
• While unfixed, the patient must lie flat
• Nurse patient on a firm mattress to ensure consistent pelvic support
• Ensure appropriate fitting of specialist equipment (e.g. pelvic binder belt)
• Maintain flat, straight alignment of whole body at all times.
• Log-roll patients
• Use spinal boards and flat-surface hoist
• If the patient is expected to have an unfixed pelvis for a prolonged period (eg. if they have no private health insurance and were not the victim of a work-related injury), to ameliorate the effects of prolonged immobility one may use continuous lateral rotation therapy using RotoRest or similar specialist beds
• Low-air-loss pressure mattresses are contraindicated in spinal or pelvic instability.

Positioning in long bone fractures

• Traction is indicated for the reduction of long bone lower limb fractures which are awaiting repair.
• This is a significant limitation on positioning
• The patient in traction is also difficult to transport
• Traction must come down for transfer fom bed to bed

Positioning for the pregnant trauma patient

• Gravid uterus restricts the use of pelvic fixators and pelvic binders
• A tilt may be required to improve haemodynamics, but it may be counterproductive for long bone traction  or spinal immobilisation
• Supine flat position may be required for spinal immobilisation, which will decrease FRC and compromise respiratory function

Competing interest

• Airway vs. C-spine collar:
  • Airway wins; the collar can be removed and inline stablisation attempted for intubation
• Head injury vs. C-spine injury:
  • Head injury wins, even if the C-spine is unstable the ICP must be managed properly. Remove the collar and sandbag the neck. Paralyse and sedate the patient.
  • If they must remain flat, then angle the bed so the head is still up.

Christie, Robert James. "Therapeutic positioning of the multiply-injured trauma patient in ICU." British Journal of Nursing 17.10 (2008): 638-642.

College Answer

Discussion

The Important spinal cord injury syndromes chapter from the Required Reading section contains a table of spinal cord injury syndromes, which is reproduced below to simplify revision.

In brief:

• The anterior cord contains motor tracts; anterior cord damage results in motor paralysis with preserved sensation.
• The posterior cord contains predominantly sensory tracts, and damage there will result in predominantly sensory loss, with preserved movement.
• The lateral cord contains ipsilateral motor/ proprioception  and contralateral pain / temperature fibers. Damage there will leave the damaged side paralysed, and the opposite side anaesthetised.
• The central cord contains motor fibers from the upper limb (lower limb fibers are more peripheral). Damage there will cause upper limb paralysis.
• The Cauda Equina governs lower limbs, bladder and bowel. Saddle anaesthesia is the key feature.

College Answer

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.

College Answer

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

• vertebral artery
• internal thoracic artery
• thyrocervical trunk
• costocervical trunk

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:

• The possibility of laryngeal/ tracheal injury and the risk of intubating the “false airway passage”. Consider tracheostomy under local anaesthesia.

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.

Discussion

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:

1. Assess for airway compromise (eg. by expanding haematoma)
   Assess for airway injury (eg. subcutaneous emphysema)
   Organise expert help.
   Awake fiberoptic intubation by an experienced operator would be ideal, with an ENT surgeon on standby. Risks include intubating a false passage, or causing complete tracheal disruption.
2. Assess for respiratory compromise.
   Ausculation and percussion may reveal pneumothorax due to injury of the dome of pleura, or the raised hemidiaphragm of a phrenic nerve injury
3. Assess the circulation in the arm on the affected side. There may be vascular compromise.
   Angiography is very important; occlusion balloons may be very useful in controlling haemorrhage from deep vessels.
4. Assess the neurology of the patient, starting with GCS.
   Verterbral artery damage may present with spinal syndromes (eg. Brown-Sequard) or brainstem stroke signs
   Carotid artery damage may present with hemispheric stroke signs

Specific concerns in a Zone 1 injury:

• massive haemothorax
• arteriovenous fistula (subclavian vessels)
• Thoracic duct damage (if it was the left side of the neck, as it tends to be with a right-handed attacker coming from the front)
• brachial plexus damage
• Horner's syndrome

Reasons for urgent surgical exploration:

• airway compromise (stridor, etc)
• haemorrhgic shock
• expanding haematoma (or, especially if it is pulsatile)
• stroke-like symptoms

College Answer

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.

Discussion

The mess we're in:

• Anaemia (Hb 65)
• Thrombocytopenia (plts 46)
• Coagulopathy (INR 1.9, APTT 43, Fibrinogen 1.1)
• Metabolic acidosis (pH 7.29, SBE -11)
• Hypothermia (temp = 34.7°C)

Immediate resuscitation:

• Primary survey should include the assessment of core temperature.
  • Haemostasis by direct pressure wherever this is possible
• ABG to determine the pH, lactate, haemoglobin level and ionised calcium
• Activate the massive transfusion protocol in liason with local blood bank and haematology service
• Organise transfusion: 1:1:1 FFP, platelets, PRBCs.
  • Haemoglobin level is not a valid transfusion trigger, nor can transfusion wait for haemoglobin levels to become available. 
  • Any transfused blood products should be warmed with a heater. Six units of RBCs at 4ºC will reduce the body temperature of an average 70 kg adult by 1ºC.
  • Crystalloid is to be avoided unless there is no other option and haemodynamic performance if life-threateningly poor
• Tranexamic acid 1g over 10 minutes
• Correct ionised calcium
• Commence warming the patient externally
• Practice permissive hypotension if permitted by the absence of neurotrauma

Within the first 6 hours:

• Serial repeated Hb measurements
• Coags data, plus/minus TEG or ROTEM (its utility and cost effectiveness over traditional coags is still being questioned) will guide the ongoing use of blood products.
• FFP 15ml/kg if APTT remains elevated
• Tranexamic acid 1g over 8 hours to chase the first dose (as per CRASH-2 protocol)
• Cryoprecipitate 3-4g (or, 50mg/kg) should be given if the fibrinogen level is below 1.5
• Recombinant Factor VIIa (Novoseven) should be thought about if the coags are trending towards normal, and the patient is still exsanguinating (the dose should be 90 μg/kg)

Endpoint goals within the first 6 hours:

• No further haemorrhage
• SBP = 80-90
• MAP = 50
• Temperature >35.0°C
• pH >7.30
• Hb >70
• INR <1.5
• APTT <40
• Fibrinogen >1.0
• Platelets >50 (100 if there has been intracranial haemorrhage)
• iCa²⁺ >1.10 mmol/L

Use of ROTEM or TEG:

• No clear advantage to their use (Sankarankutty et al, 2011)
• Positive experience with both systems has been reported
• Slightly different transfusion strategies will result, depeding on which modality is used
• A major advantage over traditional coags is immediate access to fibrinolysis data

Evidence for the use of tranexamic acid in trauma

• CRASH-2 Trial (2010):  multi-centre international RCT; 20,211 patients in total. The trial-based dosing regimen was 1g of tranexamic acid within the first 3 hrs, followed by an infusion of 1g over the following 8 hours.
  • The all-cause mortality improvement was small (14.5% vs 16%) but reached significance because of the truly massive number of enrolled patients.
  • Similarly, the improvement in mortality from bleeding was also small (4.9% vs 5.7%)
  • The greatest improvement in mortality was seen in patients who received it earlier: 1 hour after the trauma was ideal. 
  • Analysis of cost-benefit had concluded that tranexamic acid was a very cheap way of saving many lives (Roberts et al, 2013).
  • Concerns regarding the increased risk of thrombosis were not supported by the analysis (in fact the tranexamic acid group had a lower rate of thrombosis and myocardial infarction)
• MATTERS study (2012): single centre observational study, 896 admissions with combat injury to a surgical hospital in southern Afghanistan. Mortality was improved in the intervention group (17.4% vs 23.9%) and the benefit was greatest among those who had massive transfusion
• MATTERS II study (2013)-  also a military retrospective observational study; 1332 patients over 5 years. Looking at whether administering tranexamic acid together with fibrinogin (cryoprecipitate) has any influence on mortality. Mortality was lowest in the tranexamic acid + cryoprecipitate group (11.6%), then the tranexamic acid group (18.2%), then the  cryoprecipitate alone group (21.4%) and finally the "nothing" group (23.6%).

Criticism of this evidence

• Reduction of fibrinolysis was the proposed goal, but no attempt to measure fibrinolysis was made.
• Tranexamic acid has an anti-inflammatory effect, which may account for some of the mortality difference (Volpi et al, 2015).
• In the CRASH-2 trial, doctors could choose to randomize or not randomize based on treatment certainty. Also, of the dead patients, only approximately 5% had bleeding as a cause of death. Approximately half of the patients in the trial did not even require a transfusion. in short, there are serious methodology concerns.
• Much of the trial intervention occurred in the pre-hospital environment, which makes it difficult to generalise the findings.
• If  the tranexamic acid was given later than 3 hours after the injury, it was associated with an increased risk of death from bleeding.
• The CRASH-2 trial did not find much evidence of increased risk of thrombosis, but the observational MATTERS study (2012),  which was conducted among "proper" trauma patients,  demonstrated that DVT/PE rates among patients who received tranexamic acid were 9 and 12 times higher (for PE and DVT respectively)

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.

College Answer

                a)                                                                                                                                              

The key clinical signs to indicate a patient has sustained traumatic asphyxiation include:

• Facial and upper chest petechiae
• Sub-conjunctival hemorrhages
• Cervical cyanosis
• Neurological signs due to cerebral edema
• Temporary loss of vision as a result of retinal edema

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? 

• Extremely controversial

Accepted Indications                                                               

• Penetrating / Blunt thoracic injury
• Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)
• Unresponsive hypotension (BP < 70 mmHg)
• Rapid exsanguination from chest tube (> 1500 mL)

 Relative Indications                                                                 

• Penetrating thoracic injury
• Traumatic arrest without previously witnessed cardiac activity
• Penetrating non-thoracic injury and  Blunt thoracic injuries
• Traumatic arrest with previously witnessed cardiac activity (pre-hospital or in-hospital)

Contraindications to resuscitative thoracotomy            

• The patient has no signs of life at the scene of injury
• Asystole is the presenting rhythm and there is no pericardial tamponade
• Prolonged pulselessness (> 15 minutes) occurs at any time
• Massive, non-survivable injuries have occurred

Discussion

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:

• Cyanosis of the upper body, especially the face
• Conjunctival haemorrhage
• Conjunctival oedema
• Petechial haemorrhages and purpura over the face, neck and upper face
• Oedema and congestion of the head
• The "brassiere sign" - petechhii and congestion of asphyxia spare those areas of the thorax which were covered by tight-fitting clothing, as it obstructs cutaneous blood flow and prevents the formation of petechii. This is typically observed in women who were wearing a bra during their crush injury, or a tight-fitting singlet as in the case of the moustachioed gentleman in the picture.

Uncommon features:

• Chemosis
• Exophthalmos
• Retinal haemorrhages and visual loss
• Vitreous haemorrhagic exudates (Purtscher’s retinopathy- Choi et al, 2010 )
• Retrobulbar (posterior orbital) haemorrhages
• Haemotympanum

Other sequelae:

• Loss of consciousness
• Seizures
• Blindness
• Hearing loss
• Cerebral venous infarction

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)

• The patient is in cardiac arrest
• The cause is blunt or penetrating chest trauma (evidence is strongest for penetrating cardiac trauma, where the survival rate is apparently 40% - JACS, 2001)
• Arrest is after arrival to hospital, or shortly before. The "down-time" should be less than 10 minutes for blunt trauma and less than 15 minutes for penetrating trauma.
• There is suspicion that reversible pathology is present in the chest, which includes cardiac tamponade or injury to the greater vessels
• Massive haemothorax (1500ml of blood in the hemithorax)
• There is sufficient surgical expertise available to carry on with a more formal damage control surgery after the patient is stabilised (otherwise, there is no point opening the chest)

Contraindications for resuscitative thoracotomy

• No signs of life witnessed in the pre-hospital setting
• Prolonged pre-hospital CPR
• Asystole on presentation, and no cardiac tamponade
• Massive extrathoracic injuries which may be unsurvivable

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.

College answer

EMST/ATLS protocol with trauma team.

Concurrent resuscitation, assessment, treatment and early transfer to spinal unit when stabilised. 

Primary survey

Airway

• Apply high flow oxygen
• Assess need for intubation
• Potential indications  
  • VC < 10 ml/kg,
  • Vt < 3.5 ml/kg  
  • Weak cough 
  • Shallow rapid breathing
  • Diaphragmatic impairment
  • Inadequate gas exchange
  • May be required to safely facilitate transfer
  • Impending airway obstruction from fracture haematoma
• If safe to do so, perform and document thorough neurological examination prior to sedation and paralysis
• C-spine immobilisation initially 
• Intubate with C-spine precautions (consider awake fibreoptic intubation) 

Breathing

Maintain normal O2 and CO2  Exclude chest trauma: reduced pain due to spinal injury and attribution of hypotension to neurogenic shock may result in missed injuries (pneumothorax, haemothorax, open chest wound). 

Circulation

• 2 x IV large bore access and fluid resuscitation 20 ml/kg bolus
• Look for and exclude other causes of hypotension including haemorrhagic shock, obstructive shock prior to attribution as due to neurogenic shock
• Vasopressors may be needed maintain MAP >70 for spinal cord perfusion, once obstructive and hypovolaemia excluded 

Secondary survey

Disability

Full neuro assessment pre-intubation if time allows

• Assess motor level – highest myotome level >3/5 power
• Assess sensory level – highest sensory dermatome with normal sensation
• Log roll and assess spine
• Anal sensation and tone
• Presence of cord syndrome, e.g. central, anterior, Brown-Sequard
• Complete/incomplete with zone of partial preservation if incomplete ASIA classification 

Exposure

Temperature control. Hypothermia a problem and should be prevented 
Full examination, from head to toe to identify other injuries. Important to be aware that lack of pain sensation will make examination more difficult

Investigations

• Trauma blood panel in G+H
• Radiology – trauma series plus CT whole spine. Low threshold for CT chest/abdo pelvis as reduced sensitivity of clinical exam, and need for transfer increases risk/consequences of missed injuries
• Consider MRI in consultation with referral centre and with regards to timing of transfer and stability of the patient 

Treatment

• Arterial line
• Central venous access – femoral route may be easier access
• Log roll 2 hourly
• Analgesia
• IDC and NGT
• Replace spinal collar with Philadelphia or similar
• Move off spinal board as soon as possible 
• Thrombo-prophylaxis mechanically
• Early liaison with spinal unit and retrieval unit
• Liaise with patient (if remains awake) and or family re diagnosis and need for transfer.  
• Prepare patient for retrieval/transfer 

ASIA classification (For reference only)

The neurological level of SCI is the lowest level of spinal cord with normal sensation and motor function bilaterally

Points that needed to be included: 

• EMST approach 
• Relevant aspects of primary and secondary survey 
• The need to document a thorough neurological examination prior to sedation and paralysis if safe to do so 
• The concept that missed injuries are more prevalent in this population and should be actively sought. 

 
Detail in above template not needed for a pass. Details of ASIA classification not expected. 

Additional Examiners' Comments: 
Many answers contained lists of EMST principles without reference to specific points relevant in this case e.g. assessment of ventilatory impairment.  Many missed the point that other injuries need to be sought and took the comment in the stem "no other obvious injuries" to mean there were no other injuries. A number of candidates referred to a neurogenic shock as “spinal shock” 

Discussion

In a number of ways, this question resembles Question 1a and Question 1b from the first paper of 2000.

The table presented below is reproduced from the chapter on the management of high spinal cord injury, and is compiled using the following sources:

• Ch.78 from Oh's Manual (Spinal injuries by Sumesh Arora and Oliver J Flower)
• Management of Acute Traumatic Spinal Cord Injury (2015)
• "Critical care of spinal cord injury (2001)

College answer

a) Differential diagnoses

• Iatrogenic fluid volume overload due to blood product/ resuscitation fluid
• Atelectasis/Collapse/ sputum plugging
• Unrecognised pulmonary contusions
• Unrecognised pneumothorax – Mech vent, line insertion
• Aspiration at time of MBA or at intubation
• Endobronchial intubation
• Transfusion related acute lung injury (TRALI)
• Cardiogenic pulmonary oedema/myocardial event
• Fat embolism syndrome
• Anaphylaxis
• PE

b) Assessment

• History
  • Details of accident
•  PMH
  • Allergies
• Clinical examination
  • Ensure adequate tertiary survey
  • Detailed respiratory examination
  • Review fluid balance and urine output
  • Evidence of generalised allergic reaction FBE – Hb, WCC, eosinophilia
• Investigations
  • Coags – ongoing coagulaopathy, 
  • Chest XRay – infiltrates, ETT position, hardware, PTx, pleural effusions
  • Cardiac enzymes – TnI
  • ECG – ischaemic changes, arrhythmia, R heart strain
  • Echocardiogram – if suspect cardiogenic component, assess LVF, or RVF for PE
  • CTPA – early for PE but possible if patient delayed in ED
  •  Bronchoscopy – if evidence of localised collapse or unexplained infiltrates

Discussion

The possible differentials must be broad. Why?

• Old guy with ischaemic heart disease
• Long bone injuries
• Extensive blood loss (thus, likely a massive transfusion)

Thus, perioperative hypoxia could have resulted from any combination of the following differentials:

• Fat embolism
• Acute MI with pulmonary oedema
• Transfusion-associated circulatory overload
• Trasfusion-associated lung injury

To discriminate among them, the following investigative steps might be taken:

History from the anaesthetist:

• Exact timing of onset of hypoxia, as related tos urgical manipulation
• Any changes in ST segments or arrhythmias intraoperatively
• Exact volume of blood products and fluid resuscitation
• Any perioperative TOE findings (if they did one)
• Ventilation mechanics and EtCO₂ trends - anaesthetists often note a sudden drop in end-tidal CO₂ concentration during a stable steady state

Examination of the patient, looking for

• Respiratory features: moist crepitations over all lung fields, hypoxia, cyanosis
• Characteristic petechial rash, usually over the anterior axillary fold and at the root of the neck, as well as on the buccal mucosa and the conjunctiva. This distribution can be explained by fat droplets accumulating in the aortic arch prior to embolisation to nondependent skin via the subclavian and carotid vessels.
• Fever
• Tachycarda
• Retinal haemorrhages
• Visible fat droplets on ophthalmoscopy
• Jaundice
• Renal impairment

Laboratory tests,  looking for:

• Thrombocytopenia
• Anaemia (sudden decrease)
• High ESR
• Fat macroglobulinaemia
• Troponin

Imaging

• ECG looking for ischaemic changes
• TTE looking for right sided strain and LV function 
• CXR looking for pulmonary oedema

College answer

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).

• Urgency of intervention – urgent
• Road transport times and road conditions  
• Weather conditions and aviation restrictions for airborne transport  
• Aircraft landing facilities  
• Range and speed of vehicle                                

 a) Team with suitable training and experience

• Clinical – adequate seniority
• Logistic – aircraft safety training and familiarity with transport equipment/environment 

 
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

• Respiratory support equipment (doesn’t need extensive expansion other than ventilator, manual ventilation equipment, appropriate gear for reintubation)
• Circulatory support equipment:
  • Monitor/defibrillator/external pacer combined unit  
  • Multifunction monitor including capnograph
  • Intravenous fluids and pressure infusion set  
  • Infusion pumps
  • Syringes and needles
  • Pericardiocentesis and thoracostomy equipment
• Other equipment:  
  • Personal protective equipment
  • Nasogastric tube and bag
  • Urinary catheter and bag
  • Thermal insulation and temperature monitor  
• Consideration should be given to alternative vascular access such as intraosseous devices  

 
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

• 300km essentially obviates road  
• Fixed wing has potential for sea level cabin but requires increased handling
• Helicopters not pressurised and may not be suitable unless terrain allows low-level flight 

The candidates needed to be aware that minimal cabin altitude is a key part of management. 

• Airway
  • ETT secured, CXR to confirm the position
  • May need suctioning if prolonged delay to retrieval
• Ventilation
  • 100% FiO2
  • Minimise PEEP (5cm H2O)
  • Check ABG, and ventilate at TV 6-ml/kg, SIMV, rate to maintain normocarbia
  • CAGE may be associated with other barotrauma so CXR to exclude pneumothorax •
• Circulation
  • Try to maintain euvolaemi
  • As on vasopressors will need CVC. CVC needs to be well secured. Probably dilute vasopressors according to retrieval regimen to ensure smooth transition
• Neurological
  • Maintain normothermia
  • Will need sedation and paralysis for transport, again dilutions as per retrieval
  • Regular check of BSL, aim 6-10
  • Should have CT to exclude differential diagnosis.
  • Copy will need to go with patient (hard copy or digital copy) 

 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. 

Discussion

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:

• Consider the urgency of transfer, depending on clinical need.
• Transfer options which are available in this scenario all have some advantages and disadvantages:
  • The timing of the transfer is less important than the safety of the patient, as recompression therapy still has a role to play even 24-48 hrs after the injury; therefore there is no imperative to transfer by air immediately.
  • If the dive was recent (within the last 24 hrs), exposure to altitude in a commercial aircraft cabin could give rise to new gas emboli.
  • One may use a pressurised cabin instead. The additional weight and the need to fly at a lower altitude increases the amount of fuel required by up to 30%, and the travel time is longer.
  • Travel by road may be up to 4 hrs. During this time, vibration in the vehicle may give rise to increased tribonucleation, whereby gas bubbles precipitate out of a solution. 

• Which of the possible options are chosen (road, fixed wing, helicopter, pressurised vs. depressurised cabin) depends on the clinical state of the patient.
• If the patient is stable on vasopressors and mechanicaly ventilated, road transport may be the safest option (i.e. one which does not promote any new neurological injury). The next best option is retrieval by an aircraft with a sea-level pressurised cabin.

Preparation of the patient

• Secure the airway with immobiliser devices to ensure the patient is not accidentally extubated in transit
• Trial the patient on the retrieval transport ventilator for ~ 30 minutes prior to transfer, to ensure that this is well tolerated
• The patient will be on 100% FiO₂ throughout this transfer; there should be no hiatus in therapy. Ensure that the transport vehicle has enough oxygen supply to last for two such trips  
• Ensure all vascular access is established before transfer, and all ports easily accessible.
• Administer thiopentone - ensure the cerebral metabolic rate is lowest in the event of worsening cerebral ischaemia. This also protects against seizures.
• Administer long-acting muscle relaxant
• Perform one last pre-transfer assessment.

Preparation of personnel and family

• Brief senior retrieval staff (this complex job is not for the junior trainees)
• Ensure accepting hospital have received a detailed handover about the patient
• Next of kin need to be updated about the trasnfer
• Medical documentation travels with the patient
• Receiving unit receives updates on transfer status (i.e. call them as you are about to leave)

College answer

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 
  • vertebral artery
  • internal thoracic artery
  • thyrocervical trunk
  • costocervical trunk
• 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: The possibility of laryngeal/ tracheal injury and the risk of intubating the “false airway passage”. Consider tracheostomy under local anaesthesia.
•  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.

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.

Discussion

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)

So, this question is about Zone 1, where all the important stuff is. 

b)

A generic approach to management:

1. Assess for airway compromise (eg. by expanding haematoma)
   Assess for airway injury (eg. subcutaneous emphysema)
   Organise expert help.
   Awake fiberoptic intubation by an experienced operator would be ideal, with an ENT surgeon on standby. Risks include intubating a false passage, or causing complete tracheal disruption.
2. Assess for respiratory compromise.
   Ausculation and percussion may reveal pneumothorax due to injury of the dome of pleura, or the raised hemidiaphragm of a phrenic nerve injury
3. Assess the circulation in the arm on the affected side. There may be vascular compromise.
4. Assess the neurology of the patient, starting with GCS.
   Verterbral artery damage may present with spinal syndromes (eg. Brown-Sequard) or brainstem stroke signs
   Carotid artery damage may present with hemispheric stroke signs

Reasons for urgent surgical exploration:

• airway compromise (stridor, etc)
• haemorrhgic shock
• expanding haematoma (or, especially if it is pulsatile)
• stroke-like symptoms

Additional concerns specific to the root of the neck:

• massive haemothorax
• arteriovenous fistula (subclavian vessels)
• Thoracic duct damage (if it was the left side of the neck, as it tends to be with a right-handed attacker coming from the front)
• brachial plexus damage
• Horner's syndrome

College answer

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 
 

Discussion

Precipitants

• One long bone fracture: 1-3% chance
• Chance increases in proportion of number of fractures, and size of involved bones
• 33% with bilateral femoral fractures

Clinical features

Symptoms of fat embolism

• Confusion is usually the earliest symptom (60%), but seizures and focal neurological signs have also been reported (all resolve completely)
• Dyspnoea
• Tachypnoea
• Haemoptysis
• Usually, with a latent period (say, some days after the manipulation of a fracture).

Signs of fat embolism

• Respiratory features are present in 95%: moist crepitations over all lung fields, hypoxia, cyanosis. ARDS-like picture develops
• Fat globules may be seen in the sputum!
• Petechial rash (in 30-60%) - alone, enough to make the diagnosis according to Schonfelds criteria.
• Fever
• Tachycardia
• Purtscher’s retinopathy: 
  • cotton wool exudates
  • macular oedema
  • macular haemorrhage
  • retinal haemorrhages
  • visible fat droplets on ophthalmoscopy
• Jaundice
• Renal impairment
• Anaesthetists often note a sudden drop in end-tidal CO₂ concentration during a stable steady state.

Diagnosis

Laboratory features:

• Thrombocytopenia
• Anaemia (sudden decrease) -70% of patients
• High ESR
• Fat macroglobulinaemia
• Hypocalcemia (due to free fatty acids binding calcium)
• Elevated serum lipase
• DIC-like coagulopathy
• ABG: respiratory alkalosis with hypoxia and an unexplained shunt
• ECG: right heart strain, RBBB

Characteristic imaging:

• CXR: florid embolism may develop into a "flocculent" patchy widespread opacities, "snowstorm appearance".
• CT chest: non specific; focal areas of ground glass opacification
• CT brain: diffuse white-matter petechial hemorrhages consistent with microvascular injury.
• TOE: may actually catch the passing of fatty globules within the heart, but afterwards - useless.

Management:

• Specific management not supported by very strong evidence:
  • Corticosteroids
  • Aspirin
  • Heparin infusion (which supposedly encourage lipase activity and discourages the formation of platelet aggregates).
  • N-acetylcysteine (based on rat studies only)
• Boring, non-specific treatment:
  • O₂ supplementation
  • Positive pressure ventilation
  • Correction of coagulopathy
  • Replacement of platelets
  • Correction of the source problem (i.e. reduction of fractures)

College answer

Christie, Robert James. "Therapeutic positioning of the multiply-injured trauma patient in ICU." British Journal of Nursing 17.10 (2008): 638-642.

College answer

Oh's Manual: Chapter 78 (pp. 795) Spinal injuries by Sumesh Arora and Oliver J Flower

Wagner, Robert, and Andy Jagoda. "Spinal cord syndromes." Emergency medicine clinics of North America 15.3 (1997): 699-711.

Lin, Vernon W., et al. "Spinal Cord and Cauda Equina Syndromes." (2003).

Maynard, Frederick M., et al. "International standards for neurological and functional classification of spinal cord injury." Spinal cord 35.5 (1997): 266-274.

Hayes, Keith C., et al. "Classifying incomplete spinal cord injury syndromes: algorithms based on the International Standards for Neurological and Functional Classification of Spinal Cord Injury Patients." Archives of physical medicine and rehabilitation 81.5 (2000): 644-652.

McDonald, John W., and Cristina Sadowsky. "Spinal-cord injury." The Lancet 359.9304 (2002): 417-425.

College answer

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)

College answer

College answer

Not available.

Discussion

This question is identical to Question 5 from the first paper of 2010 and Question 15 from the first paper of 2015.

College answer

Not available.

Discussion

The differences in management of this patient compared to a non-obese patient:

A different pattern of injury is to be expected:

• Injury scores are lower in obese patients (Arbabi et al, 2003)
• Pattern of blunt trauma is different (Boulanger et al, 1992)
  • Injuries that are more likely:
    • pulmonary contusion
    • rib fractures
    • pelvic injuries
    • knee dislocations (Fuchs et al, 2014)
    • extremity fractures
    • proximal upper extremities seem to get it worst (Evans et al, 2011)
  • Injuries that are less likely:
    • head injuries
    • liver injuries
• "Obese people injured in vehicular crashes had a similar injury pattern with no difference in seating position, direction of impact, seat belt use, and ejection."

Differences in managing the airway of a morbidly obese trauma patient:

• Difficult airway; difficult bag-mask ventilation more likely than actual difficult intubation.
• Short handle may be required for direct laryngoscopy; most people would just resort to the videolaryngoscope.
• When intubating, the FRC is small and the patient will become hypoxic rapidly, which means fewer attempts will be possible.
• Increased risk of obstruction, even when awake
• When obtunded, a virtual certainty of obstruction

Differences in managing the ventilation of a morbidly obese trauma patient:

• Poor chest wall compliance
• Increased risk of atelectasis
• Obesity hypoventilation syndrome
• Difficult access for chest drains
• Difficult windows for trauma TTE
• Difficult auscultation and percussion, eg. for pneumothorax
• Increased aspiration risk

Difference in managing haemodynamics in a  morbidly obese trauma patient:

• Difficulty measuring accurate blood pressure (need for appropriate size cuff)
• Realistic possibility that no cuff will be appropriate and arterial access may be required
• Difficult IV access- CVC as well as PIVC; the college answer recommends to go straight for the intraosseous needle
• Intraosseous access is hardly fool-proof and can also be frustrated by obesity, considering especially the likelihood of there being bilateral knee prostheses
• Possibility of pulmonary hypertension, cor pulmonale or CCF makes haemodynamic management more complex

Difference in managing sedation, analgesia and C-spine protection in the morbidly obese trauma patient

• Likely, CO₂ retention and narcosis (influences doses of induction drugs)
• Medullary sensitivity to CO₂ will be even more reduced by opiates
• Some sort of syndromic condition may complicate neurological assessment (eg. Prader Willi syndrome)
• Log rolling will require additional assistants, or some sort of unusual equipment.

Differences in the investigations 

• Morbid obesity is one of the limitations of FAST
• Difficult insonation of the appropriate spaces; image quality is likely to be poor
• Pericardial fat can be misinterpreted as clotted blood
• Perinephric fat may be misinterpreted as intraperitoneal free fluid
• The advantage is, if you can't fit into the CT scanner this is all you've got.

College answer

Not available.

Discussion

a) 

So let's go through those abnormalities and list their explanations. This list is probably longer than what the examiners would have expected, as this 3-mark question could not possibly have expected all the problems to be listed. One can assume that for a full mark perhaps only six or so important points would have to have been raised from the investigations, and these are identified at the very end.

• The patient is anaemic, because trauma.
• The MCV is on the lower side of normal, which makes you wonder whether some of the anaemia is chronic
• The white cell count is elevated, which is likely a  neutrophilia due to the acute stress
• The INR is elevated, as is the APTT, and the fibrinogen is low, suggesting that the coagulopathy is due to factor depletion. Two possible (and not mutually exclusive) reasons could be consumption in clotting, and dilution by prehospital crystalloid resuscitation

Now, the gas:

• The A-a gradient is increased. (713 × 0.5) - (33 / 0.8) - 150 = 165 mmHg.
  However, the patient is not hypoxemic. This A-a gradient can be explained by the chest injuries, and could represent pneumothorax, lung contusion, aspiration, fat embolism, or simply the poor V/Q matching of the severely empty patient.
• The patient is mildly acidaemic
• There is a mild metabolic acidosis (SBE is -6.0)
• The CO₂ is appropriately low;  it should be 34 mmHg if you calculate it by subtracting the SBE from 40. If you are calculating it using Winter's formula, it is  (14  × 1.5) + 8 = 29, in which case you'd think there is a mild respiratory acidosis. It is impossible to know which of these approaches the college wanted us to use, but - looking at the stem - the narrative that fits best is the one with the decreased respiratory drive, as the patient is said to be obtunded.
• The anion gap is (139 - 105 - 14) = 20, i.e. it is elevated.
• The lactate is raised, which is surely contributing to the anion gap elevation. The lactate elevation can be explained by haemorrhagic shock.
• If one accepts 12 as the ideal normal AG, the delta ratio is therefore (20-12)/(24-14) = 0.8, which suggests that this metabolic acidosis is mixed, a combination of a HAGMA and NAGMA (but trending towards a pure HAGMA). This extra little contribution from non-anion-gap causes can be explained by a couple of litres of pre-hospital saline, which fits the "dilutional coagulopathy" narrative.
• Lastly, the ionised calcium is low, mainly because calcium is an essential cofactor in clotting, and will be depleted by massive blood loss. Given that we are made to believe that these results were taken "on arrival to the Emergency Department", the alternative explanation in trauma (citrate due to massive transfusion) is less likely

Thus, the most important abnormalities to note are:

• Anaemia, due to haemorrhage
• Coagulopathy, which is dilutional and consumptive (likely due to haemorrhage and normal saline resuscitation)
• Metabolic acidosis, which is due to a combination of
  • hyperlactataemia, due to haemorrhagic shock
  • excess chloride, due to normal saline resuscitation
• Inadequate respiratory compensation for acidosis, due to decreased level of consciousness
• Hypocalcemia, due to consumption in coagulation

b)

"Fluid and haemostatic resuscitation" implies that the college expected the trainees to give this coagulopathic patient more crystalloid, which is perhaps the opposite of the term "haemostatic". Reading between the lines, it feels like the college wanted to explain the rationale for haemostatic resuscitation, and then to discuss the place of fluid choice within that rationale, meaning not necessarily "fluid" in the conventional watery sense, but more as volume. What follows is an attempt to construct an answer that would achieve this imaginary goal:

Haemostatic resuscitation for this patient:

• Correct hypothermia by rewarming
  • Rationale: hypothermia impairs the activity of clotting factors and the cardiovascular effects of catecholamines
  • Rewarm with external warming device, eg. air circulation blanket
  • Warm all fluids and blood products with a warmer
  • Minimise heat loss by exposing only parts of the patient being worked on or examined
• Correct acidosis with volume resuscitation
  • Rationale: acidosis is a negative influence on clotting function, cardiac output,  and propensity to arrhythmias
  • Most of the acidosis here is due to the lactate, which is being generated partly by the sympathetic response to hypovolemia, and partly by the tissue hypoperfusion
  • Volume resuscitation should correct this 
  • Any crystalloid being given should be a "balanced" crystalloid to prevent any contribution from hyperchloraemia
• Correct hypocalcemia by replacing calcium
  • Ionised calcium is an essential co-factor in the clotting cascade
• Correct coagulopathy by using mainly blood products for resuscitation
  • Use  "balanced" blood product transfusion (1:1:1) of platelets, plasma and PRBCs
  • Rationale: coagulopathy will develop if packed red cells are the sole resuscitation fluid; clotting factors also need to be replaced, in a proportion that resembles whole blood
• Aim for a MAP closer to 70 to defend CPP until TBI is ruled out
  • One cannot set haemostatic endpoints lower than normal ("permissive hypotension") because the patient has a decreased level of consciousness and could have a traumatic brain injury,
  • Once a CT is performed to exclude the possibility of CNS trauma, one may change to a lower blood pressure target to prevent blood loss and reduce the need for aggressive volume resuscitation
• Correct hyperfibrinolysis with tranexamic acid
  • Hyperfibrinolysis is a consequence of severe trauma; tranexamic acid is a safe and arguably effective method of protecting patients from this complication

College answer

Whilst most candidates scored reasonably well in this question, many candidates answered the question with a to narrow a focus on the neurological findings, rather than the broader features e.g. prognosis/other organ dysfunctions/interventions when asked to compare and contrast. This aspect of the question was which was worth 60% of the marks

Discussion

To defend the trainees, "features" here would immediately make the stressed exam candidate think of "clinical features", especially as the stem goes on to mention a "neurological level". Most reasonable people would agree that it would have been fairer to explicitly ask for "prognosis/other organ dysfunctions/interventions" if this is what was expected.

The definitions below come from the 2019 revision of the ASIA classification statement

a)

Complete spinal cord injury:  an absence of any sensory and motor function in the lowest sacral segments (light touch, pin prick at S4-5, DAP, and voluntary anal contraction) (i.e., no “sacral sparing”).

Neurological level of injury: the most caudal segment of the spinal cord with normal sensory and antigravity motor function on both sides of the body, provided that there is normal (intact) sensory and motor function rostrally.

b) Four incomplete syndromes: only four are asked for, but there are in fact five listed by ASIA, and probably more that are theoretically possible.

1. Central cord syndrome
2. Brown-Séquard syndrome
3. Anterior cord syndrome
4. Posterior cord syndrome
5. Cauda equina syndrome
6. Conus medullaris syndrome

c) To contrast "the features of a complete SCI and central cord syndrome at neurological level of C4" would benefit from a table format:

College answer

Aim: To explore the clinical issues of ventilated trauma management.
Key sources include: Paper 2020.2 Q14, same topic with a different approach. CanMEDS Medical Expert.
Discussion: Many candidates did well in the advantages and disadvantages section with a reasonable understanding of the disadvantages (of MRI particularly) and the relative sensitivities of the two modalities for different injuries. More emphasis on safety concerns would have improved some candidates’ answers.
Candidates could improve their answers in the indications section by reading the details given in the stem. The NEXUS criteria are not relevant in an intubated patient.
Incorrect indications included “as part of a routine pan scan” and “neurosurgery or trauma request it”.
To improve this answer the senior ICU practitioner should detail WHY the referring specialities are interested in ordering these scans for the treatment of the ventilated trauma patient. Adding these relevant facts would have allowed candidates to demonstrate depth of knowledge and score more marks.

Discussion

Question 14 from the second paper of 2020 asked for the same CT-vs-MRI comparison but only allocated 40% of the marks to the answer.

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.

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.

College Answer

Syllabus topic/section:

2.1.20 Radiology in Intensive Care.
2.1.13 Trauma Intensive Care – L1.

Aim:
To explore the clinical issues of ventilated trauma management.

Discussion:
This question is a repeat from the 2023.1 March paper and the candidate answers have improved in the quality, attention to detail and depth of knowledge of this core topic from the previous sitting.
The marking examiner noted that some candidates achieved a high score with only 1 page of writing if it was well structured and concise. This is a useful fact when considering time management strategies in the examination. This answer benefits from a tabulated structure and most candidates were able to take advantage of this.
Marks could have been gained by considering that 50% of the marks were allocated to the discussion of indications for both modalities, marks were missed because they prioritised the advantages and disadvantages to the exclusion of a section that had equal mark allocation. Candidates are advised to use the marks allocated to manage time effectively during the written examination.
The disadvantage of having to remain in a collar while waiting for an MRI under GA was omitted by many of the candidates. Most had also failed to mention the prognostic advantages of being able to image the internal structure of the spinal cord. Some candidates referred to MRI as the "gold standard", without specifying which structures it is the gold standard for. Many candidates referred to contrast as being a disadvantage of either modality, but neither modality requires contrast for the evaluation of C-spine injury.
Many candidates wrote about the rationale for CT or MRI (e.g., good at picking up ligamentous injuries) rather than the indications as the question asked (e.g., a patient with abnormal neurological examination needs an MRI even if CT doesn't detect an injury etc).
 

Discussion

This is a repeat of Question 12 from the first paper of 2023.

College answer

Syllabus topic/section:

2.1.13 Trauma Intensive Care / Spinal trauma: L1
2.1.8 Neurological Intensive Care / Spinal cord disorders: L1

Discussion:  

Candidates who had a good knowledge of longstanding tetraplegia and the corresponding pathophysiology did well. Candidates who had limited knowledge of the disorder but were able to apply general knowledge of management of spinal patients (e.g. bowel care and patency of IDC- very important in this patient population) were able to gain some marks.
The marking rubric is included to aid the candidate's future study

Discussion

• Clinical features:
  • Headache
  • Dizziness
  • Nausea
  • Shortness of breath
  • Visual disturbances
  • Palpitations
  • Facial flushing, nasal congestion and sweating above the spinal lesion (baroreceptor-mediated vasodilatation)
  • Cold clammy skin with piloerection below the lesion level 
  • "Autonomic conflict"- cardiac arrhythmias arising from competing massive sympathetic and concurrent vigorous parasympathetic activity
  • Hypertension is the dominant finding, and leads to complications, such as:
    • Myocardial ischaemia and pulmonary oedema
    • PRES and intracranial haemorrhage
    • Seizures
• Prevention strategies:
  • A - if the patient was intubated, you would extubate as soon as able, as these patients will have frequent episodes of dysreflexia in reaction to the ETT. If not intubated, they would have an NGT, and it would be a priority to remove oit.
  • B - avoid noxious airway stimuli, eg. suctioning 
  • C- Keep the circulating volume in the lower body by raising the head of the bed
  • D - even though there is no pain sensation, analgesia helps prevent noxious stimuli from triggering the episodes. 
  • E - Maintain normal electrolytes so as not to give the gut a chance to do an ileus
  • F - maintain good urine output, support good hydration, prevent urinary retention by intermittent catheterisation.
  • G - Maintain regular bowel regime with aperients and enemas (the goal is to prevent constipation)
• Management:
  • During a hypertensive crisis, 
    • Lower the legs and elevate the head (Trendelenburg position)
    • Check the usual suspects:
      • Tight binding clothes
      • Urinary catheter/bladder (retention?)
      • Bowels (constipation?)
      • Pain (give empirical analgesia)
    • Use short-acting titratable agents:
      • GTN patches or nitroglycerine paste (2%) onto the skin above the spinal level
      • Nifedipine and prazocin also sometimes used
      • Clonidine, hydralazine, labetalol, captopril, all are seen in the wild
  • Long term:
    • Botox injections
    • Intravesical capsaicin
    • Transurethral sphincterotomy
    • Sacral bladder denervation via dorsal rhizotomies 
    • Malone anterograde continence enema (MACE)

College answer

Syllabus topic/section:

2.1.13 Trauma Intensive care / Spinal Cord injury: L1

Discussion:  

This is a repeat question which overall was moderately well answered by most candidates. Clarity and specificity are required when describing neurological findings. Correctly identifying contralateral vs ipsilateral findings and detailing mechanisms of injury is important in this question. Lower marks were related to omission of bowel/bladder clinical findings. Candidates are advised to revise lateral medullary and central cord syndrome in their preparation.

Discussion

This was a repeat of Question 15 from the first paper of 2015, except that time, the candidates were asked for two mechanisms.  The Important spinal cord injury syndromes chapter from the Required Reading section contains a table of spinal cord injury syndromes, which is reproduced below to simplify revision.

In brief:

• The anterior cord contains motor tracts; anterior cord damage results in motor paralysis with preserved sensation.
• The posterior cord contains predominantly sensory tracts, and damage there will result in predominantly sensory loss, with preserved movement.
• The lateral cord contains ipsilateral motor/ proprioception  and contralateral pain / temperature fibers. Damage there will leave the damaged side paralysed, and the opposite side anaesthetised.
• The central cord contains motor fibers from the upper limb (lower limb fibers are more peripheral). Damage there will cause upper limb paralysis.
• The Cauda Equina governs lower limbs, bladder and bowel. Saddle anaesthesia is the key feature.

College comments

Syllabus topic/section: 2.1.13 Trauma Intensive Care

Discussion: 

Candidates who scored well in part a) provided a structured list of injuries relevant to the case. Conversely answers that lacked structure tended to miss relevant injuries and this then correlated with missing complications in part c). The above standard answer concentrated on injuries relevant to the stem, including pelvic, complex lower limb (including vascular) injuries and crush injuries including rhabdomyolysis.

Blood transfusion management in part b) was generally well answered. Many candidates did not put equal emphasis on fluid administration, which was equally important, given the significant risk of crush injury and associated rhabdomyolysis. Both Blood AND fluid management was asked for in the stem. Easy marks were lost due to not following the question directions.

Given the history provided, complications secondary to crush injury with rhabdomyolysis and vascular injury were required for an at standard answer. A broad range of complications in part c) was required and better answers included those of therapy (eg MTP) as well as complications from the different injuries sustained. Examples of complications likely for this patient within the first 72 hours include AKI from both traumatic mechanisms and therapy, complications secondary to potential haemorrhagic shock and subsequent massive transfusion, complications of long bone fractures including fat embolism, compartment syndrome and ischemia from threatened vascular supply to the lower limbs.
 

Interpretation

a)    List the likely injuries (3 marks)

The stem presents us with a clearly crushed person. The clues in the stem include:

• "for a prolonged period" suggests a crush injury, and indirectly suggests a sustained period of poor blood flow or uncontrolled haemorrhage
• "from the waist down" suggests mostly lower limb and pelvic trauma
• "slow rolling 4- wheel drive car" gives an approximate height for the crush direction (i.e. for a sedan one would be looking at knees and ankles instead)
• "a brick wall" suggests a rough surface and abrasions
• The vital signs suggest uncontrolled shock
• "obvious bruising extending from his lower abdomen to just above his knees" suggests haemorrhage as the cause of the shock
• "blood at his penile meatus" suggests urethral or bladder injury,  as well as pelvic fractures

This "list" question is weighed three marks, which suggests that something more than just "crush injuiry, rhabdo, pelvic fractures" was expected. A general rule is that a "list" like this scores more marks if it is ordered and categorised. For example:

• List of injuries:
  • Bony injuries
    • Pelvic fractures
    • Femoral fractures
    • Sacroiliac joint fracture/dislocation
  • Muscle injuries
    • Crush injuries to thigh and pelvic musles
    • Interruption of lower limb blood supply
    • Rhabdomyolysis secondary thereto
  • Organ injuries
    • Bladder injury, urethral or ureteric injury
    • Sigmoid colon and rectum could also be affected by  sharp edges of pelvic fractures
    • Genital injuries are also plausible
    • Secondary AKI from rhabdomyolysis
  • Nerve injuries
    • Femoral nerve
    • Sciatic nerve
    • Sacral plexus
  • Vessel injuries
    • Femoral artery dissection/transection
    • Femoral venous thrombosis due to stasis
    • Pelvic venous plexus bleeding
  • Systemic consequences
    • Reperfusion-associated systemic inflammatory response
    • Electrolyte derangement due to reperfusion and rhabdomyolysis

This is 97 words, i.e. something representative of a 5-mark answer. Systemic consequences were not asked for and would probably not have scored many marks, but then the college commentary lists rhabdomyolysis as an injury, which one might argue it is not (one could characterise it as a post-injury systemic syndrome resulting from muscle necrosis)

b)    Outline your blood product and fluid administration over the first 24 hours (4 marks)

Blood and fluid were asked for. The abundant mark allocation suggests that the examiners expected a considerable amount of detail, and that the management steps could afford to be very specific. Thus:

• Overall endpoints:
  • Prior to haemostasis:  SBP ~90 (permissive hypotension)
  • Post haemostasis:  MAP > 65, urine output of 1-3ml/kg/hr (AAST guideline, 2022)
• Blood product administration
  • Severe shock (shock index, HR/SBP = 150/80 = 1.875)  suggests the need for massive transfusion 
  • 1:1:1 ratio of red cells, clotting factors and platelets - warmed during infusion
  • Fibrinogen replacement as factor concentrate or cryoprecipitate
  • correction of ionised hypocalcemia, acidosis, hypothermia - to reduce blood product use
  • Ongoing transfusion to be guided by TEG and coags
• Fluid administration
  • Prior to haemostasis, prioritise blood products
  • Balanced crystalloids after haemostasis; rate of 400ml/hr, up to 1L/hr, titrated to target urine output
  • Total fluid dose in the first 24 hrs needs to balance the risk of increasing tissue oedema and worsening compartment syndrome
  • Isotonic or concentrated bicarbonate can be considered to alkalinise the urine, but the evidence for this strategy is weak 

Mutschler et al, 2013, observed that patients at this end of the spectrum required about 10 u PRBCs on average.

c)    List the complications you would anticipate in this patient during the first 72 hours (3 marks)

Again, a list with lots of marks attached suggests a need for more than just a basic unordered pile. Ordering this by systems may have value.

• A: the need to remain intubated for repeated interventions
• B: ARDS due to systemic inflammatory response/reperfusion and TRALI
• C: Vasodilated shock state +/- ongoing intravascular volume depletion due to blood loss and compartment shifts; compartment syndrome of the lower limbs requiring fasciotomy; vascular injuries requiring stents , embolectomy or bypass 
• D: significant analgesic requirements
• E: hyperkalemia, hyperphosphatemia, hypocalcemia, metabolic acidosis
• F: AKI with potential need for RRT; haematuria following bladder/urethral repair; suprapubic catheterisation; urine leak and urinoma
• G: Interruption of GI tract following repair of any sigmoid/rectal injury, and/or ileus; pelvic haematoma 
• H: consequences of massive transfusion, including TRALI
• I: fevers resulting from peritoneal contamination and/or SIRS

College comments

Syllabus topic/section: 2.1.13 Trauma Intensive Care. Traumatic Brain Injury L1

Discussion: 

To achieve high marks, candidates should move beyond generic TBI management and demonstrate a detailed understanding of pituitary dysfunction in the context of TBI. High-scoring responses acknowledged the diagnostic challenges of detecting pituitary injury in acute trauma settings.
Strong answers differentiated between acute and delayed manifestations of pituitary dysfunction, emphasizing the importance of early recognition and management of life-threatening hormonal deficiencies—particularly ADH (diabetes insipidus, SIADH) and cortisol (secondary adrenal insufficiency). Candidates were expected to outline the implications for fluid balance, sodium abnormalities (hypo-/hypernatremia), and haemodynamic stability.
Focus on ICU-relevant considerations was essential, with clear delineation between anterior and posterior pituitary involvement. High marks were awarded to those who addressed diagnostic approaches and appropriate hormone replacement strategies, tailored to the acute phase of critical illness.
An overarching statement may help such as:
Assessment for identifying pituitary injury in the context of TBI is complex due to overlapping features. Anterior and posterior pituitary abnormalities in the acute phase need attention with a focus on ADH and steroids. While thyroid, Sex hormones, GH and prolactin can be investigated after the patient has crossed acute phase of trauma.

Part a) – Candidates that included all components of history/examination and investigation pertinent to the pituitary injury were awarded more marks. Since it was an outline question summary of assessment was sufficient. Assessment required the candidates to mention features in history and examination that would put a patient at high risk for pituitary injury and include the clinical presentation. Candidates could score higher marks if they mentioned multimodal investigations including relevant biochemical, endocrinological and radiological investigation.
For example: assessment would include history/examination and investigation. A focused history would include –
1)    Mechanisms of injury that could subject a patient to higher risk of pituitary injury- acceleration and deceleration injury or associated base of skull fracture
2)    Clinical features suggestive of ADH/Addison’s- GCS, refractory hypotension

Part b) - Answers that included how they would manage sodium dysregulation and refractory hypotension and its effects on severe TBI scored higher marks. A safe approach to managing -SIADH, DI, hypocortisolism was expected to score good marks.
 

Interpretation

a) Assessment of suspected pituitary injury:

• History:
  • Old age
  • Front-facing deceleration injury mechanism
  • Base of skull fracture
  • Diffuse axonal injury
  • A higher severity of TBI
  • Severe shock (eg. Sheehan syndrome)
• Examination:
  • CSF rhinorrhoea
  • Clinical findings suggestive of base of skull fracture
  • Cranial nerve findings that raise suspicion of trouble around the cavernous sinus (i.e. 3d, 4th, 5th, 6th nerve palsies, and bitemporal hemianopia)
  • Unexplained shock
  • Polyuria suspicious of DI, with very dilute urine
  • Bradycardia
  • Postural hypotension
  • Unexpectedly slow neurological recovery, somnolence, lethargy
  • Unexpectedly labile blood pressure in response to stress (eg. sepsis)
• Investigations:
  • Hypernatremia or hyponatremia
  • Hyperkalemia
  • Hypoglycaemia, not otherwise explained
  • Low pituitary hormone levels
  • CTB evidence of sella turcica fracture, or a base of skull fracture more broadly
  • MRI of the pituitary is the gold standard on imaging

b) Management of suspected pituitary injury:

• Supportive management:
  • Correct electrolyte abnormalities
  • Address the associated haemodynamic problems empirically, i.e. defend the BP with noradrenaline to achieve a MAP/CPP target that will perfuse any normal pituitary tissue that is left
• Specific management:
  • Acutely, only the consequences of DI need directed management:
    • Desmopressin, or
    • Vasopressin infusion
  • If SIADH is the main manifestation:
    • fluid restriction
    • demeclocycline
    •  
  • In the long term, also hormone replacement: 
    • Hydrocortisone
    • Thyroxine
    • GH and potentially oestrogen/testosterone