You are on page 1of 5

TRAUMA MANAGEMENT Acute management 1 Survey Danger o Ensure patient and staff safe to continue assessment and resuscitation

n Response o Unresponsiveness suggests CNS failure, severe hypoxia or hypotension, airway obstruction, aspiration risk Airway o Assess for obstruction, patency o Use airway positioning, suction, adjuncts (oropharyngeal Guedel, LMA, ETT, cricothyroidotomy) o Maintain c spine Breathing o Ensure adequate ventilation o Assist ventilation if hypoventilating o Give supplemental 100% O 2 at 12L/min Circulation o Obtain IV access o Fluid resuscitation: 3ml for every 1ml lost; give 20ml/kg if hypovolaemic shock o Stop external haemorrhage o Assess response to resuscitation: pulse, BP, cap refill, skin colour Disability o AVPU + pupils Exposure, examination, environment Examine fully, document, obtain Hx from any source 2 Survey GCS Examine entire body for external signs of injury Record pulse, BP, RR, temperature Xrays: CXR, lateral c spine, pelvis
o o

Compound leg fracture 1. IV access 2. Give: pain relief, antibiotics, tetanus booster, sedation 3. Reduce # to close to anatomical 4. Apply sterile dressing 5. Splint and arrange transfer to orthopaedic centre

Head Injury History Cause of injury Setting in which patient was found Did patient talk before losing consciousness? o If yes, 2 cause of LOC eg. hypoxia, hypotension, haematoma, seizures Diabetic? Insulin injections? Eating properly? Drug user? Alcohol? Depressed? Recent stress? Medications? Epilepsy? Twitching? Urinary or faecal incontinence? Recent accident? Headache? History of hypertension? Weakness of limbs? Examination Breathin GCS Pupillary response: equal/unequal, reaction brisk/sluggish/unreactive, change since injury Focal CNS signs Lacerations of face or scalp Check for neck and spine tenderness Check for CSF leak Investigations E/LFTs, BSL, FBC, blood alcohol, coags, toxicology, ABGs Management goal = to prevent secondary brain injury Oxygenate (ensure airway, give O2, intubate if GCS <8) Avoid hypercapnoea Maintain MAP >90-100 Avoid anaemia o Keep 30 head up Observe 4 hours if mild head injury; rapid transfer if severe head injury Investigations CXR XR lateral c spine XR pelvis XR lateral skull (if # present, increases risk of intracerebral haematoma to 1:4) Indications for CT head GCS <9 Neurological deterioration (eg. 2 points on GCS) Drowsiness or confusion Headache, vomiting Focal neurological signs # Penetrating injury >50 yo Epileptic seizures Risk factors (eg. anticoagulants) Indications for transfer GCS <12 at 2 hours Abnormal pupils Focal neurological signs Persistent headache or vomiting Preparation for transfer Discussion with neurological service

SNAKEBITES
***9/10 snakebites dont have envenomation

Signs and symptoms (suggest envenomation) Neurotoxic o Ptosis, dysphonia, dysphagia, drooling, diplopia, progressive muscle weakness Myotoxic o Myalgia, tenderness, weakness, myoglobinuria Local bruising, bleeding Nausea, vomiting Cardiotoxic Headache, LOC, visual disturbances o Arrhythmias, arrest Dyspnoea, respiratory paralysis Nephrotoxic Extremity weakness or paralysis o Renal failure, renal cortical necrosis Haemorrhage, ecchymosis Initial management 1. Keep patient as still as possible 2. Compression o 15cm crepe bandage extending 15cm above bite site 3. Immobilise o Australian snakes can cause shallow envenomation, causing the venom to enter the lymphatics o Lymph movement is facilitated by the milking action of active skeletal muscles, and the pulsations of nearby arteries (decreasing movement slows lymphatic flow) 4. Do not give alcohol, food, stimulants, or use tourniquet 5. Transport to medical facility for definitive treatment (bring snake if possible)

History 1. Was the bite witnessed OR were the circumstances such that a bite may have occurred 2. When was the patient bitten 3. Description of snake (colour, length) 4. Geographic location 5. Timing and type of first aid, and activity following bite 6. Type and timing of symptoms 7. Past history: allergy, past antivenom exposure, renal, cardiac or respiratory disease, medications (eg. anticoagulants) Assessment Evidence of bite (cut hole in bandage) Swab for venom detection DO NOT WASH WOUND Look for signs of envenomation at site (lymphadenopathy) Assess for neurolotoxic paralysis, muscle damage, coagulopathy, urine output, general Sx

Investigations Observations: vitals, mental state, signs of coagulopathy Venom detection kit: wound site (best) or urine Urinalysis: blood and protein Bloods: coagulation screen (INR, aPTT, fibrinogen, d-dimer, FBC, E/LFT, CK) Management if antivenom is available 1. Secure and maintain airway; give 100% O2 2. IV access and slow IV infusion N saline 3. Monitor vitals 4. Swab bite site / collect urine and blood (venom detection takes 30 mins) 5. Give SC antihistamine cover 5 mins beforehand: keep adrenaline, O2, steroids on standby 6. Dilute specific antivenom (1 in 10 N saline) and infuse slowly over 30 mins o If anaphylactoid: stop infusion, give corticosteroids, wait 30mins, restart infusion at slower rate SPECIFIC SNAKES Genus Pseudonaja (brown snake) Most common Neurotoxic (paralysis, weakness), procoagulants antivenom is available Genus Oxyuranus (taipan) Most potent Neurotoxic, procoagulant, myotoxic (rabdomyolysis, muscle damage) antivenom is available Genus Acanthophis (death adder) Highly potent Neurotoxic antivenom is available Genus Pseudechis (black snake) Highly potent Myotoxic), anticoagulant (renal failure) antivenom is available Genus Tropidechis (rough scaled snake) Moderately potent Neurotoxic, procoagulant, myotoxic, renal failure is common antivenom is available (tiger snake antivenom may be used) Genus Notechis (tiger snake) Neurotoxic, procoagulant, myotoxic antivenom is available Sea snakes & sea kraits o Neurotoxic, myotoxic, 2 kidney damage, hyperkalaemia, NO coagulopathy antivenom is available (tiger snake antivenom may be used)

SPIDERBITES Two groups of spiders cause significant envenoming: Red Back Spiders and Funnel Wed Spiders

Red Back Spider (Latrodectus hasselti) Clinical Features 50% minimal symptoms; bite site appearance is variable Lactodectism o Severe pain within 10-50 mins o Local pain spreads proximally, becoming regional or truncal o Local, regional or generalised sweating o Headache, malaise, nausea, hypertension Management No admission if minimal symptoms Antivenom only if signs of envenomation 1. Have adrenaline and resus equipment available, but no premedication required 2. 2 vials IM or IV diluted in 100ml N saline, administered over 20 mins 3. Repeat in 2 hours if symptoms incompletely resolved Funnel Web Spider (Antrax robustus) Clinical features Usually bite site is painful with puncture marks present Piloerection, tongue fasciculation, increased lacrimation Tachycardia, hypertension, pulmonary oedema Nausea, vomiting, headache, decreased consciousness Management IV access Give antivnom if any signs of envenomation o 2 vials CSL Funnel Web Antivenom IV o Up to 8 vials may be required if severe

You might also like