Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

and high that everyone, um my name's in world. I'm I'm a emergency and promise surgeon. On day I worked as a major trauma fellow at ST Marys Major Trauma Center in London. At the moment on, it is my great pleasure to speak to you about trauma assessment on blunt splenic trauma. It's not a very long presentation and hopefully will be quite interactive. Um, and I'll be happy to take any questions at the end. So let's start. So the first thing we're going to talk about is, uh, basically just a brief guy to the assessment off the trauma patient. Could someone just let me know if you can hear me well enough, someone on mutant, just say yes or no. Yes, thank you very much. Okay. So brief guides discussing with the trauma patient I like to call this a TLS and more cause events from a life support is something that we're all very familiar with. But there's some little extra bits that we add in our major trauma centers. So when the ambulance crew are evertors is bringing patient, you arrives in the resource pay. These are the two bits of information and the structure in which they should deliver it. So we have something called on act missed hand over, and this is how the paramedics will give you the information. And it's also, if you were bringing a patient how you could put the information forward to your colleagues so that it's in a very structured way, and it helps to deliver that information to the individuals that you're handing over to. So for the at missed underwear, you identify who the trauma team leader is. There is quiet in the room, and you begin by telling them what age your patient is, what time the accident happened. What the mechanism of injury waas. What the injuries, where that you found or suspect either on your examination or from your observations. What signs you found such a sub survey. Shins, BP, heart rate. Um, GCS on what treatment has been given in the field at such a Z maybe IV fluids or blood paracetamol or around easier antibiotics or any such thing, And they also should tell you the sample history on this is repeated as you'll find when we go to the Prime Research survey. But essentially, that's does the patient. Have any known allergies? Often minute patient is delivered to you from an incident or a mass casualty, or or just a road traffic collision. Sometimes very little is no better than the patient can be unconscious. But if known things like allergies should be stated, what regular medication they're on of patients being speaking any past medical history and the details of that on what time they last at and drank, and also the events that led up to the instant after you've done your atmos turned over or received, you're at missed handover. You move forward to your initial assessment, and I hope everybody is familiar with an A B C D E approach to examining on assessing patients. And this is by the advanced from a life support course. It's It's that principles. It's the structure that they put forward. And the key principle here is really that it's a structured assessment with Cymbalta, a knee issue resuscitation. So if you find something in A, you don't move to be until you've done something about it and it goes in an A B, C D E manner, or, as you'll see later, a C A B C. D E Manor, because the idea is that you treat the the aspect that's going to kill the patient first. On the sequence of that is, if there's a problem in the airway that's likely to kill the patient before problem breathing before a problem in circulation, disability or exposure. So for your primary said, Hey, it's aimed and identify and treating life threatening injuries in need of immediate management are surgical intervention. So that's what the primary survey is evening to do. As we said, there's an A B c D E approach on that, as I said, prioritizes Theus ass mint on the treatment according to the priority of which they would threaten the patient's life. Excuse me? Ask to the promise every move on to a secondary survey on that's ahead to to examination, which is aimed at identifying that there any other injuries that may be in need of treatment in the short term. And then there's a tertiary survey which is done on the ward typically a little while later needs to be done within the 1st 24 hours, which is a head to toe examination again. But this time the amis to ensure that you haven't missed any injuries. For instance, I can recall, um, a teenage boy who fell from a height and had a pelvic dislocation which was relocated in the E. D. And later, when he got to the ward, him he had a foot drop. And we can talk about that later. Someone remind me so primary service from a survey in trauma on the bit that we add on this catastrophic bleeding. So you want to, um, look for that and address it first before you start with the airway because catastrophic bleeding is going to fill. First on, that's very obvious. Um, heavy bleeding from either extremities that are visible or there's a lot of blood on the floor, and that's through the use of turn a case and pressure and dressings. The airway is the next part that you want to address on. There you're looking to see is the airway patent. You simply speak to the patient if they can respond on. But, um, then you know that there are always probably patent if they can speak clearly. You're also looking at the C spine here. You also want to know is the patient awake enough or able enough to maintain their airway? Or are you going to need to think about intubating that patient that really quite quickly you? Then if everything is all right in the airway, you said load patient patients have low back. You move on to breathing, breathing again. You want to know is the trickiest central you're thinking about tension? Um Flores ease. Um, you want to know? Is there equal air entry? Um, and expansion. And again, you're thinking about pneumothorax. And as per my last talk, you don't want to miss attention. You know, with oryx, which will shift your track here to the opposite side. It'll be hyper isn't on that side. And you have no breath sounds on that side. And you're also looking to see if there's any chest wall injury. What does the chest look like? Can you feel the clavicles? And is there a step? Is there step in the sternum? Is there obvious surgical emphysema when you feel the rib cage is the pain there all things that my age to think about, fractured ribs and again you more hemothorax or other injuries to the thoracic cavity, and then you want to think about what other respirations on one of their SATs and all day normal. And if they're not, you're going to deliver oxygen. Um, you mail doesn't I don't see taking some blood and an ABG as your resuscitated on. That's an example of giving oxygen how you resuscitated as you're assessing and remember, you usually have a least three people in your team. If you're unlucky, there's only two, but generally this four or five people, and then you move on to circulation. If you've dealt with breathing now, the other thing says you would stop breathing if the turkey and watch shifted. If you did suspect attention, you know, for aches and you would deal with it there and then before you moved on to circulation on, then you would reassess after your intervention on then make your way back through the ABC. And when you get to see this very obvious things like circulation, what is the rate on the rhythm off the pulse? What is their BP? What's the capillary refill time? What are the heart sounds like? Is it one and two plus zero? Is there, added sends, Um, are they muffled might be a tampon up like we talked about last time. Muffled heart sense. What about disability? Well, that's mostly about GCS or afternoon. Yeah, looking at the level of the patients consciousness and leading towards suspecting head injuries or just a lot of blood lust will drop your GCS a swell and then exposure is about examining the patient thoroughly without clothes, but kept warm as we talked about last time, and it includes temperature and glucose. Does anyone have any questions on the primary? Serve it just before we move on. Yes, not go ahead. It's a quick question. Always was in my mind as a medical student. For example, if you are on the street and you see such incident, uh, do we have to intervene? And if we do have to what extent we expected as the medics Okay, there's something there's no so the good to marathon act. There's something called a good Samaritan neck, but you're going on voyaging into some legal aspect, so I'm by no means an expert on, but essentially, the Goods Marathon Act says that if you feel that you have on the right skill set in order to be able to help at an accident, then you may do so on. But there has never bean a case brought against a doctor who has done that. But at the same time, there's no obligation for anybody to stop and to help. It's down to your own ethics. I would say. That's very kind of you. Thank you. I have a question, please. True. So we start with the C A B C D. My plane, isn't it? Like, if I start given a lot of time for, for example, to stop the bleeding, uh, and, uh, to stop the bleeding and the breathing also is affected? Wouldn't that be like, should I ask for help off another person to do things in parallel to them are officially, absolutely should. But the way the trauma team was set up, and perhaps I didn't talk about that enough is that you have a trauma team leader. That person's quite experienced in running trouble cause they stand at the end of the recess trolley and they direct operations. Typically, you've gotten anything test on ODP at the top end, looking after the airway and analgesia on sometimes cumulation. Then you have a doctor who's doing the primary survey. Then you have another doctor, medical student or nurse who's taking the Bloods putting on, um, the BP cath on the other. The SATs probe in the other cardiac monitor on, then. So, in that way, you've got somebody to get access put on monitoring, for you've got something looking after your airway. You've also got someone else come and get stuff for you as you need it. So generally there's a least 4 to 5 people, and and so the person doing the primary survey yes, can continue with the primary several. But the the essence is still the same. If you have a problem with the airway, it must be dealt with before moving onto breathing. And if, like you say and two are coexisting, then yes, you'll deal but simultaneously and you actually find that you can actually run through a primary survey in less than five minutes. And the fact that something needs to be dealt with in a sometimes doesn't mean that you stop your primary survey because they couldn't get out with the anything test. But traditional teaching is that you should stop deal with that part before you move on and reassess before moving on. Thank you. So, Doctor, do you do you check eyes for people Really Reflexes? Yes, you do. That's part of your GCS after just gas. Yes, you should. You should do that again. That's giving you information on head injury. I got questions. So you said you mentioned that it's normally a team or four or five people. And then, if you're quite junior in that team on your know, able to do something with someone else, take over. If you're struggling to do something in particular Oh, yeah, A good team leader will identify who they've got, what this girl set is and how to support them on. But you might even be tasked with just describing or doing the Bloods on you. Someone else will take over. So I would say, Get involved when you can observe and then trying to Bloods, and we'll do describing or put our help. The nurse. You know, there's lots of different things you can do but just get stuck in so that you can get all the experience you can get. Think, let's we want a little bit because I'm just conscious that we might run that time. So any other questions? Just save them for the end. And perhaps we'll stop again in a little bit. Okay? So just thinking about your lab junks to prime resurvey. Next. Um so the adults the primary surgeon survey are things that you do sort of at the end of the primary stairway to try and advance your diagnosis on or to help you to identify life threatening problems s so that you can deal with them. So chest X ray. So you might say, Well, if the patient is stable, why would I do a chest X ray? I'm going to go for CT, and it's much more sensitive. It's gonna give me much more information. And there are points where, um, trauma team leaders. We'll just go to CT. But if you suspect any sort of chest injury a tall, I think it would be wise to do a chest X ray on. That's just really to make sure that you're going to be taking that patient's CT and the Safeway, and there isn't a big new floor extreme with or X attention that needs a chest room before you move to CT and the things to bear in mind. Then it's that often chest X ray can be got quite quickly and recess pain in some hospitals, it also sometimes chest X rays. Next two C t on the time it would take for you to bring the patient there, um, is the same a CT. But alternatively, you have to think that maybe you can get a portable very easily and recess. But CT is quite a little distance away. So you have to think about how your hospital set up on what your resources. Airlie. Similarly, a pelvic X ray. If you suspect a pelvic injury, um, it could be very useful to know what the pelvis is like on dot Certainly the case. If you suspect pelvic trauma on down, certainly there should be a public binder on if you suspect pelvic trauma, and then you could do any faster. Um, because thinking about bleeding, we talked about the fast, I think in my last lecture, where essentially, you're looking for fluid within the abdomen, but you're also looking a heart for temp in a little on the chest. For new Thor, it's a human for X, but most surgeons would say that the really critical on element of the fast fast scanning is to tell the surgeon which cavity to open when the patient is not stable enough to go to CT on. Most would prefer to go straight to CT in a stable patient because it gets more information. The only caveat to that is in a penetrating injury where we've a nifty my patient was stable. I would want rule uh, sh um, a penetrating injury to the heart and a tampon art because, as we talked about before, it only takes 50 mills within the pericardium in in order to prevent venous return, prevent the heart feeling, um, and cool shop. So you would want to know about that. And there is a period where the patient is very well, but then they plummet quickly and you don't want to be in the CT scanner for that. And then the CT stand itself is often done in modern trauma centers as, um, a single pass C t. So they give the contrast of different stages it and then they scan two points on, so you're essentially doing a portal, venous and arterial phase within the same scan, and it's called a single pass and comes from the Army. And actually, it's comes from the experiences in Afghanistan, so they're the adjuncts that you might do. Two. Primary survey. Your secondary and tertiary are really, really injury specific in some ways, but in other ways, they're just really important to do. So. After say, you don't headed off to the CT scanner on, do you come back to the trauma being you've decided on where your patients going to go? That's the time where one of the doctors would do a head to toe examination, just looking for evidence of other things, like fractures that might need, um splinting or may need cast or lacerations or bruising that might make you think about other injuries on bruises. That's about right. Sorry about that. Um, and then tertiary survey is essentially, uh, a repeat had to toe, but it's done later when the patient goes to the wart. Okay, I'm going to take three questions are just to clear up secretary and tertiary before we move on to the Spanish tour because I don't run that time. We got a case to talk about, so I think there was a hand up. So why didn't you want me yourself and ask your question. Thank you, Doctor, Regarding the secondary and tertiary survey, so does it. This involve all the major systems? Are is just looking at the physical appearance on the patient? It No, it's all the major systems, but it's head to toe. Thank you very much. Anyone else to clip for a move on? No. Okay, let's make one right. So let's talk a little bit about your spleen and trouble, so this will be a picture. I hope that's familiar to you but spleen, And that means fairly straightforward. It's in all the text books, not something that needs spend lost time on. But just to say, you know, it's 11 to 13 centimeters. It's It's in the left of quadrants of injuries to the left side, particularly the left quadrant or left chest. You want to think about your spleen, particularly as underlies the nights to 11 ribs, so of ribs of fractured within that area again, Think right, explain on also think about. If you are heavily suspecting Hispanic injury well, what other structures or or it or organs are associated with the spleen and lie in the same sort of territory. So you've got the anterior surface of your left kidney. As you can see in the picture, you've got a splenic flexure of the colon, um, inferior. You funds the stomach stomach being removed. In this picture, you've got the tail of the pancreas, and then you've got the diet from which is essentially a Z, you know, separating the abdominal from the chest cavity. So that's just a quick little run through Hispanic anatomy just to help you out. So what about once don't trauma? Well, it is the most commonly injured solid organ from blunt trauma, which is why I have chosen to speak right. It today on the mortality still remains about 7% worldwide, and that's despite theater. Cancer is in trauma care, and particularly in the West on 3% have associated Kalanick injury. And if you think back to the picture that we just saw, that's not hard to understand. Is it? Because if you had a fractured rib in that area or the blunt trauma was sufficient enough, then you you're going to get injuries to the other surrounding viscera. Okay, so Now we go to case. So you remember we talked about at missed a little bit earlier on so a stands for ages. So this is a 56 year old gentleman on The accident happened 40 minutes ago. It was a blunt trauma from a road traffic collision. He was the passenger, and the impact was to the left side of the car. He had left sided chest and flank abrasions on examination, and he was tender over the ninth. 10th rib. His heart rate was 90. That pressure was 100 over 60. Esprit a shins were 22. SATs were 95 on 15 liters on the interventions of the treatments that have been given were too wide or cannula inserted 10 mg of morphine, T x A, which is tranexamic acid. Anyone was at my last, like, two will know about that as well. First dose. Okay. Now, before we move on from here, can I have a few shadows? So what? People are thinking? What type of injuries do you think this gentleman might have? Splenic injury? Definitely. Because it's still up sided. Just implant corporations. Very said road as well. Yeah. What's the what loss of blood. More like blood. Yes. Very good. And why you, Colonel Hemorrhaging the, uh, the depression is lower. That's right. And what else of people thinking is I'm reading inside. Let's move away from hemorrhage for little minutes. Waiting for attention in Clorox happened where they put in the two white or cannulas. But, um, bit confused. Why they put in two as opposed to one whiteboard. Canyon is sorry. I thought, Sorry. I was thinking of, um, test strains. Yeah, I was thinking of a big grey cannula in the in the apex. My dad? Yes. So this patient doesn't is, like does likely have maybe a newer for X. Well, could have any methotrexate, right? One respiratory failure, haven't I? Don't know that you could say that. They have. Ah, bad type one respiratory failure. Good. Um, but again, you didn't want going on at the moment. But if you keep things simple, you just want to think I could these injuries be so they could be in the left chest and they could be and they're the two most likely at this point. Yeah, okay. On the observations. You see, so you have a reasonably stable patient. Agreed. Okay, so let's see what happened next time we said so Very was maintained and patent there was reduced our entry in the left base. There was some surgical emphysema. There was no clinical flail sacks. 1 96 on 15 liters. Heart rate was 90. That pressure come up a little bit. One turn over 60 paramedics had given to 50 of crystalloid on the CRT was for second. So a little bit slow, slightly agitated again May lend to blood loss. But JCs was 15. People's were equal and reactive to light. And in the ample history, they were fitting well, with no known drug allergies and we're on no medication. Say, what shall we do next? Which of the adjuncts do you want to do most? Okay, one vote for fast. Anyone else? One do anything else? Get it. Depression is terrible. Correct. Okay. Anyone else? We've got a few people saying ct in the chart. We've got X ray Communist. Well, see Teeples body. Okay. And you know what? Every one of those answers is correct, Okay? And this patient is stable, so you could just take them straight to see to the barrel. Mind what I said earlier? We have got reduced our entry. We have got some surgical emphysema. We don't want to miss a big tension pneumothorax or a big new Thor X that might expand whilst we're going to CT. So I would recommend that we do a chest X ray first on this guy. And then very mind what I said about fast coming so fast. Scanning is better than clinical examination alone for detecting intra abdominal hemorrhage. But it's not perfect. It's operator dependent on death. Think, uh, if you recall the last lecture, there are some false negatives. So if the bleeding is in the retroperitoneum, you will have a negative fast. But actually, the patient is bleeding on CT is probably better for this patient because going to give us more information. We don't need to rush off to theater straightway. Okay, so let's see. So this is the chest X ray on. This is the C tape. Um, can I, um, have a shout out for what you see on the chest X ray clear association with the before it's been more likely explosively business fracture. He was literally fusion with the minister. Correct so you are seeing the meniscus. But a meniscus just means this fluid in the chest, correct in the context of trauma, in particular. Blunt trauma. Road traffic collision Given the observations that you have the likelihood of Scout says it's quite correct. It is most likely to be human, for X is also broken rib Doctor. Sorry, very good. Yes, they're awesome. Broken ribs and you can see those more clearly on the CT. I think, um, and it's very subtle, but there are there is one other finding on your chest X ray. And then you went there right side. No, this clean doctor look like just tell you anything about spleen. Is there nothing displaced a shin? No, it's very subtle, and I think it's not a projecting well in a few to see. But with the day there is a little pneumothorax in the Avonex. But you'll have to believe me on that because it's very hard to see on the X ray. There's more of the other thing to say is if you have a hemothorax, the chances of you not having a new month or so really quite small because they injury that's caused the hemothorax is usually a broken room, and therefore you're nearly always going to have an associated pneumothorax. So this patient has a hemothorax? Is quite a big team with oryx, isn't it? How much blood do you think? My eyes. Who it? Punchy, modern 50 miles, obviously. Definitely. Hold on. 50. So if I tell you that it takes 200 mils to blunt your cost of phrenic angle, then how much do you think all those? 600? Yeah. Yeah, I think so. There's probably a better later in that. Yeah, which is probably accounting for the drop in the saturations. Um, so much we need to do next history. Drain it. Yeah, I think that's great idea. Drink. So you gonna put in chest ring? Yeah. So if you go to the maneuver, it sternum. Yeah. Then that's the second intercostal space. And then walk your way down in your men, which, um, can be crossed. Large trauma portion of the trauma population, Certainly within the UK, penetrating. And then the nipples are very good guide because they relate to the fifth intercostal space. You can just slide your hand across and you can see the anterior order and post here borders are marked, which are pack on Lotus, Um, a store. So I and then the bottom of your triangle is marking the fifth intercostal space. So that's called your triangle of safety on if you put your chest strain in that triangle anywhere in that triangle, In fact, then you are pretty well assured that you probably wouldn't do any damage. Does anyone know anything specific about putting your chest during in relation to the position of the drain in relation to the rib? Yes, I So if you mention the ribs are kind of like so it's not keeping me your rib space is no, that's fine. Doesn't matter. So you try to glide on the top off the rib. So where your nerves are If you were to, let's say go underneath the rib, you will hit the nerve on that and and actually you can even get an artery. It well, actually, you can take it with a lot more damage. Um, yeah, I don't know. That's correct. Mild. Um, Garrett. So essentially, your neurovascular bundles runs on the bottom off the inferior surface of your rib, so you want to be putting your finger and feeling the top of the rib and guiding yourself along the top of the rib. Okay, so we put a chest training on. It's a very small picture, but there is a test. A ring here. Okay, this is the CT abdomen. Pelvis. It's sort of giving it away little bit, but I want, um if someone condition Priebke the other findings. So we've got a great four Spanish class aeration on do that. Sort of seen my was little line here and and by these abnormalities, along with spleen here. But what else do you see on that scan going for you? Consolidation is usually found in the chest. And this is the abdomen. This usually the president's, um Tony? Um um, a peritoneum again, That's I doubt it. I see what you're saying, and it's possible, but when you have one slice, it makes it really difficult. But what I would do is I would put this into long windows and then we'll bring myself down until I saw the lung markings had disappeared. And then I would know I was in the abdomen, and I would know then that that that's probably still within the lung cause we're quite high up. But it could be it could be anything else. Is there a lot of pelvic floor disorder? They won't. Ah, program Rohit's. Is it called pelvic floor disorder? No, no, not this one. Definitely not called a perfect floor disorder unless your pelvic floor has moved up to the level of your kidneys, which should be quite unusual. No, I'm not sure what you're getting at of a scientist. Really low fistula, other No, I run. Being thought. Hated what I wanted. Teo. Yeah? What's that? That's fine. Yes. So it's fluid, isn't it? Yes. So, in the contrast in the context off a grade four splenic injury, what do you think that is? Another. Very good. That's all I wanted. You're 40 Sophisticated. Just want to blood. So here's the blood. Um, this shows a blush. So that's the contrast coming out of the vessel showing active bleeding within spleen. This is blood around the spleen. Okay. And this is fat stranding that we call, which is subtle. Sign that there's trouble going on. Okay. So great for spending class aeration. These are the grave's or spinning class orations. These air taking from the American Association of Surgeons and Trauma on which put out quite a lot of classifications. But this one is quite useful and really to go through it, um, is a little bit boring, so I'm just going to let you read it. But essentially the grade fours and fives, you have to be thinking, Do you need to go to the theater? Because this degree of the injury in all terms nowadays, we look at all of these five, and if the patient is hemodynamically resuscitated to normality or near know Maliti, then we do not automatically take these patients to theater. But you have to think about where you are on what your resources are on whether or not you have access to embolism, a Shin Onda high dependency unit to monitor. So it's sort of given the game away. Then we've got a stable patient. There's no contrast. Expectation? I told you there was. I'm changing my mind. Um, there's a moderate humor. Peritoneum, as we saw on there are no other injuries within that scan, which would mean you need to go to the theater. So in this case Ah, yeah, go ahead side Thank you, Doctor. Look, is this we're not taking two a pressure because of the code guidelines. Are is it just because it is grateful we're not doing anything because the patient is stable? I think in most European countries we adopt a essay on non operative management of blunt trauma with the success rate of up to 90% Um, on a canvas highs 99% depending on the great of injury. I'm for a great for five on the success of non offer to management obviously fools the best and come for a slows 45%. So it has to be the right patient, but we'll get on and discuss that later. But it has nothing to do with covert. No, nothing I told think. It's just that we've got very good at managing them nonoperatively on. We've had a lot of years of experience off What ones will do? Okay, on what one's weight. Um, and therefore certainly within the UK, we adult a non up to management for a stable patient, regardless of the great. Okay, um, so in case off stage five where we have here damage, is it better we'll perform a splinter back to me and and remove all of this plane or all this pain. Okay, In my opinion, it probably is. But there is still a number great fives that will get away with no no to management. And the rules are still that if the patient is hemodynamically, well, you can try non operative management. But in those cases as well come on. To talk bad, you need to have some specific things that you need to be able to do in order for that to be safe. One is having access to embolization. The other is having a rapid access to theaters if the patient deteriorates 24 7 and the other is having somewhere high dependent that you couldn't wanted to your patient. So, considering all of that, here we are with our patient on their grateful and there's no active bleeding. They do have a moderate hemoperitoneum and they don't have any, Uh, any other injuries that make the decision simple would make us go to better. So what does people want to do? Where do you wanna go? First of all, what? Where do you want to go in terms of where in the hospital. Step down to trauma or Okay, you are to the er one vote for the ward. One for er for the operating theater. Hasty watching Weight. Hates do you want? You might. Okay, so that's two wards known operatives anywhere else. Any other options? I've got intensive care unit. Yeah. Yeah. There's one other place that might be quite useful if you had it. I see you. No one of them. Maybe Thursday. How much is he? Surgical, Right. Interventional radiology. Oh. Mm. Yeah. This is a very complicated diagram from the Western Society for Emergency Trauma Surgery and Trauma on, uh, I put the reference there four years you can have a look at it in your leisure, but essentially, it's your decision making for spleen. Trauma goes on the basis whether or not patient is stable or unstable or a transient responder. And you can see on this side of the column if they're unstable or a transient responder, if they're positive fast, they're probably gonna have this. They go straight for a laparotomy. Yeah, and that's pretty clear cut. And that's really the whole of trauma surgery. If the patient is unstable, then they go to the theater, That's it. And you don't have what you find. If the patient is stable, then the everything becomes a lot more complicated and the greater there to guide you because they they sort of help you determine how high your rate of success it's going to be. But at the same time, these are guidelines, and you can see in the fours and fives here you would go for and geography on Dem Bill is a shin. Okay, so we can go non operative management alone. Or we can go if we've got it known up to management and and, um, Bill is a shin, this would be one suggested regime for non operative management on Essentially, it's done by grade on it really just reflects on how much attention you should be painted. Your patient gives a rough guidance on how often you should be doing the hemoglobin and examining their belly and when you should do your repeat scan. And it's everything we know about managing. Spleen's nonoperatively comes from Children, and so it's not quite the same, but we use it anyway. And this is the best that we've got. Um, see, you can see from that, what we need to be doing. So everyone gets cereal examination. Great one and two don't need. And, um, Bill is a Shin Grade three should maybe have it considered in hours. Grade four and five should have it done emergently. So if the patient is stable, that's we should go there. Not steady already gone to the theater, and everyone should have their scan repeated within three days. Why's that? Anyone know? Yeah, all right, I have a question. What is your approached by letting this pain you by itself, even if the patient few few think, Do you think it is until recently so it can heal by itself? But the patient might be feeling something, So if it's a great tube and this pain is very good, it's not that it healed itself particularly. But if it's no bleeding on, there's a small hematoma in the body will deal with that, and even if it's not bleeding in the human time was quite big. The body will eventually deal with it, and you will maintain some Spanich function on. That's important for the reasons that we all know to do with immune function and encapsulated bacteria on, but we are at about 40 minutes. I'm gonna have to move on a little bit quicker now, and that's you've got some time for questions at the end. So this is the criteria for known up to management. Another citation for you if you want it. And this again comes from A S T. The American Association of Surgeons and Trauma. And basically, it's what I've already described. I'm everyone should have a CT. If you're going to manage the nonoperatively, you can manage. I'm great three and fours only if continuous monitoring is possible, you have 24 7 access to optimize the attorney and in terms of embolism, a shin any grade with the pseudo aneurysm or contrast. Extra visitation should be considered for embolization, but you should do it pre emptively in your grades for in fives, and that will increase your success. Known up to management. Don't worry about the proximal distal bit was bit too complicated, but it does a healing on. Then you repeat CT for threes and fours, irrespective of embolization, and that's because you're looking for a studio aneurysm. This is the rationale for non operative management. Essentially, there's low failure rates from 1 to 4. You can see that increases up to 70% for Grade five. So I'm with you. However we were talking to earlier. It's a great five I don't really want to hang around on. It's likely I'm going to remove that spleen, but 1 to 4. You can see that the failure. It's really quite low, you know, even in a great fourth, nearly 70% of patients are going to be able to keep the spleen, and the overall failure rate is only top percent. And I've put a reference therefore a systematic review and meta analysis, which showed failure rates for Grade four was at 43% and Great five's at 83%. So slightly different figures but further failure rates After embolism Asian, you can see that they decrease significantly down to 17% for a four and 25% for a five, which is why they rare, which is why they recommend that we do pre emptive embolism a shin for grades form five to increase what we can get away with nonoperatively complications of non operative management or obviously delayed smell rupture 50% for grade three. In a blush, seen that's where you'll get a delayed splenic rupture and 70% if you have a significant hemoperitoneum. So why don't we just take the spleen? Knows we're really because, um, Op C, which is overwhelming postsplenectomy infection. It's actually quite low, you know. It ranges from 10.12 23% but actually it's not even that high. I think that should be 2.3 and the good missing your full stop there. And really, we're talking about Children and people with hematologic a lot of abnormalities of this plane in those higher categories. But if it does happen in the mortality is very high. So everybody wants to guard against it as much as possible. And as we said, risk of encapsulation bacteria. But then you have to think about your complications after laparotomy balancing it out. Wound infection, hernia, pancreatic fistula leak. Yes, so and your embolize a shin. I was going to run through this really quickly because it's not really something that you need to know at this point, but I just want me to be aware of it, and the reason why we use it And, as I said, there are indications are for grade for five, where this contrast expose Shin, which means there's active bleeding. But the patient is stable for pseudo aneurysm of any great cause. A pseudo aneurysm means that that it was a high likelihood of rupture on further bleeding and the same with an eight, uh, venous on arterial venous fistula of any grade. Um, and you success rates over 90% for Andrew, um, Bill is a shins and grade bond three and a 3 to 90% and 45. But actually, we don't recommend that you embolize grade ones to three unless there's active bleeding because of the risks off. Um, and you're embolization itself. These are the complications of embolization failure to control bleeding so it fails in 10 to 15%. We still got theater. You can still do that. You're not lost anything, Mr Injuries, because you've embolize and you haven't had a look inside In function on and abscess, it's about 20% causing sepsis vaccines, a low molecular weight heparin. It's recommended that we should give it to patients undergoing non operative management, but there's a lot of controversy in the literature's toe when you should give it. Most people would give it if the patient's being, um with stable hemoglobin with no signs of active bleeding for 48 hours. Vaccines, patients Where Model a racer If they've had this peanut Andi, even if they've had it embolized for a four or five. Um, you should give Pneumovax and repeated up five years on him off. Less influence a once a meningococcal ones. And that's just a brief summary blown up to management, as I said, recommended for your stable patients. All grades, Um, there's higher failure rates for fours and fives, and that's why we immobilized was also higher rates. When you're injury severity, score is higher. So which tends to mean that those injuries and other parts the belly is, well, where the human paratonia ms Significant, although that's being challenged more recently and repeat CT to look for the pseudo aneurysm. Like we said. And as we said, the very important take home messages. Don't try manage known operatively unless you have the facilities to do it, and summary from Bill is a shin. Then we've said everyone who's got extras a shin old grades. Those have a pseudoaneurysm or Navy fistula. These are the complication rates low molecular weight should be given and vaccine should be considered. Right now, I'm gonna move on to some questions and sorry I had to fly through the end of it, but I wanted to have loads time for questions. So if you stop sharing so maybe I could see people, Guys, if there's no need to raise your hand If you've got a question, you can just you and Dr, you know, be able to I'm Doctor. I've got a question about the primary survey. Say, if you think the airway is compromised on about the same time you think there's a problem with C spine, what do you do first in such a situation? Airway first, so you would manage the airway. But you would protect the C spine at the same time, so you would maintain in line stabilization and C spine. So it means that you shouldn't be extending the net, can order to intubate. You have to do it in line, think. And my doctor, um, when we are testing the stage off splenic trauma, do we assess it through, like CT or any imaging Or do we assess it through, um, surgery in surgery? That's a really great question. It's done by CT. So all of those grading stairs are based on CD, Um, but it can't be interrupted. But essentially, yes, those grading zar all based on CT findings. Thank you so much. Gosh, I must have explained everything really well. No one's got any more questions. It was a great lecture doctor for more questions regarding the in the beginning, doctor use the patient was given Morphin on Pandemic Acid. So it will be really worried about the priority distress at that time when we see the patient giving morphine, especially at the high doses. Uh, we don't worry about that, Thank you. I think it's humane to treat pain. We can deal with the effects quite well. And 10 mg. Not really. That march I'm in and I got patient off 70 kg or above. Um, and you might find that sometimes, actually, fentanyl is use Depends what people have on. Do you know fentanyl can be given at 50 and micro grams or 25 or aliquot 25? Um, say yeah, but I would treat the pain and this patient's in a lot of pain. We can manage any respiratory effects that it might have it. It's not going to really have any respiratory effects that 10 minutes 10 mg I wouldn't have thought so. We have a question on the chart. I run in regards to one of the cases. Why was low real? Actually Weight Heparin Given So low molecular weight Heparin should be given, um, with a soon as your patient is deemed to be, um, stable from bleeding point of view So most surgeons won't give depending on the greatest panic injury. But really, with any human paratonia more greater Spanich injury above one, people would usually wait 24 hours and then if the hemoglobin had been stable. Um, if there had bean no change in the clinical examination off the abdomen, Um, then most people would give low molecular weight heparin prophylactic dose after 24 hours. Some would wait 48. But that's as I say this, um, controversy in the literature about it. And although it's recommended you started, assume is possible, there is some controversy about Just assume that should be on. I guess the back question to that is Why do I want to give it on diets? Because something we haven't talked about it yet. But trauma patients, um, our initially, um, bleed a lot. And so they're they're prone to bleeding in the beginning. Um, but they then switched to a very thrombotic phase, which they're at higher than average risk off getting DVTs and peas. And in fact, we see up to 5% of our patients get whatever called Inova Peas with in the absence of DVT's, just from this hypercoagulable itty phase during trauma. And that's why we would want to start a little molecular weight. Heparin assumes it was safe to do so. Um, is it is a reason why we see and blood screening form a lot more. Is it due to the position of the spleen? Where's located? Is that Solbes and or Yeah, Yeah, I think it's exactly that. I think it's protected by the ribs, but it's also affected by the ribs and ribs and damaged. It doesn't really have, um, any of the other organs sandwiching it and protecting it in quite the same way as, say, kidneys have, um so, yeah, I think it's to do with the position on it's proximity to the pleural cavity in proximity to ribs that tend to be fractured on damaged in blunt injury. Well, we to have, uh, two more questions in the chart. You can come, uh, compression hose. You re be used as opposed to a low molecular weight heparin. Mm. So compression hose three or Ted stockings should be used as well. Um, Andi, if that's all you can do, um then, yes, but we would typically use, um, Ted stockings plus low molecular. What happened so physical? A swell. Assume chemical prophylaxis. Um, all mechanical prophylaxis on defy couldn't give low molecular. What happened then, if I had the facility, as I am lucky enough to do, and in our trauma center, then I would use a pneumatic boots Flowtrons, which pumped the cars up and down, which simulate there, cath pump during walking. Thank you, Doctor. Uh, we've got, I think, two more questions. Listen, let's put his hand up, but I'll just answer. I'll just ask the question in the chapter At what type of blood transfusion would you give in this injury? What type of blood transfusion? What do you mean? I'm not sure the evening. So, um, the type of blood. Trans. I assume that you're asking what I give Hold blood. Would I give the components part such a Z And, uh, yeah, I guess that's something. Ring half you can cook. And so if I had the luxury of having whole blood, I would give her that because it's better. But the jury is still out on hold that it's certainly, um, has everything that you need. And if you there are some studies that show that component parts are not as good as the home. Some American studies basically have commercial, and it's being used by the military for a very long time. So ever had it. My personal choice would be whole bad. I'm in the UK That is not something that we have available. So I would give one toe want one, like we discussed in the last lecture, which is balanced damage control resuscitation on which address is both the changes on the possible problems with coagulation as well as the loss of blood. But also you're giving blood because you need oxygen carrying ability to prevent the tissues from no having enough oxygen from a metabolic demands. And as we heard last week, that's or two weeks ago. That is the definition of shock. No. Think that that we do have a hand raised. I Listen, if you would like the all skill question and then meet yourself. Yes, Doctor. Um, in some injuries that you have the the final the skeletal is being into with this. Which off? The examination will you do is when you're on this. So you're Blasco Coma scale should help you with that s o Is the patient able to move? Um, on also your secondary survey on the patient Move with that pain. Is there any your extremity examination Should be looking for the newer vascular status of the limbs. Um, and also should be palpating secondary Several. You palpate the spine on, see if there's any tenderness on the pins and needles. Anything to make you suspect that there was a spinal injury. Um, of course, there are more difficult problems where spinal injuries I'm going to cause changes in your BP. Um, but that's a different topical to cover, but yes, the spine and spinal injuries. Very carefully. Assess Fold in secondary survey It depends on. What? What's happened? And you know what you're finding on your primary survey as well? I've got a quick question. So you get your first day. So ctx a the 1 g 1 g on, then your second. So when would you decide about giving a second gram of eight hours? Would you? You know what? What would you look for? It was it the crash trial? Was it that recommends that takes a don't know about the second the second gram. How do you so crushed to travel s? Oh, yes, eso Generally speaking, if it's been given Prehospital then there's been a high suspicion of bleeding. If a suspicion for bleeding continues, then I would give the second. But you need to give the fast within three hours. But obviously the second takes eight hours to give, but I would give it a soon as possible. So generally we give it in recess. We started in research. Anyone else? Well, that seems to be well. Thank you So much dot So yeah, keeping to time. Well done. Everyone is there. Is there another lecture you need to run off? Two on? Not right now. Next one is at seven. So we do have a bit of a break. Oh, good, good. Well, go and have a cup of tea or something. And I think what we'll do is, um I'm on call for trauma or next week, so I'll see if there are any interesting cases on Baby, I'll just keep a little log and come do a quick one in a couple of weeks time. Right? So I'll see you again soon, right? Think that much for today. Thank you. Thank you. Thank you. Bye. Thank you, Doctor. Things you don't set.