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Um Hi, Doctor Sahu. I'm trying to invite you to the stage. So um let me know if it's working for you. Um Yeah, and then we can wait a couple of minutes for more people to join and then we can get started. Hi, everybody. Thanks for joining. Um We're just going to wait until about maybe 35 past or a bit later for everyone else to join and then I'll hand over to Dr Sahu who will be delivering our first session on trauma. So yeah, we'll just be a few minutes. Is this working? Uh Yeah, but we can see your whole screen. So can you see this? Yeah, brilliant. So I'm really hoping this works. Um So we can still see the whole powerpoint and your whole screen. Not just the powerpoint. Is that better? Yeah. Perfect. Nice. We're on OK. To me. Amazing. Awesome. You can hear me fine now. Yeah. Yeah. And running through this, you can see, can you see my mouse? We can, yeah, you can't or you can, we can. Perfect. That's fine. Awesome. All right. Well, I'm ready to go whenever you guys are. Ok. Um We're happy to start now. We'll wait a couple more minutes. It's up to you. Really? Yeah. How many people have we got on? Uh there's eight of us so far? Nice. I mean I can give it a couple more minutes. Ok. Um Lovely. Ok. Yeah, we're just gonna wait a couple more minutes guys and um if you have any questions during, during the session or after, feel free to put it in the chat um because I don't think you can, uh, use mics on this one. So, yeah, if you put it in the chat and then I can let er, Mr Zah, you know. All right. Yeah, we'll just be a few more minutes. Cool. Um, close enough I think. Have we got any more or we just, we do go, uh, yeah, we've gone up to 10 but yeah, happy to start if you are. Yeah, brilliant. All right. So, hi guys, I, I'm a course surgical training, uh, in my second year and currently in New Cross Wham, this is a talk on trauma and what I feel you guys should know. I mean, I'm aiming this for final years but I know you guys, there'll probably be a spread of people and, uh, this is aiming for you guys to become somewhat comfortable with trauma. I know you're not gonna be until you've got a bit more experience under your belt, but at least know what you should do or ought to be able to do when you've got a patient that's come in with sort of a major trauma type of situation and you're an fy one doctor because most of you are going to be that probably this time. Well, in a few months time, hopefully. All right. So aims today are how to approach trauma. So that's the primary survey, secondary survey, trauma history and imaging. And the asterisk is as an fy one doctor because the more you progress, the more will be expected and put on you. And you know, a lot of this will be taken by sort of senior people within the team. And this is what I want to emphasize is that it's a trauma is dealt with as a team, no one person will just deal with trauma on their own. And as fy one doctors, even though you're the most junior members of that team, you're definitely not useless. You are very valuable and you can do a lot, particularly if you get comfortable with the content, I'm gonna give you today. So without further ado primary survey. So in terms of doing a primary survey, most of you will be familiar from sort of your A IP module uh that it's a basic A to e slightly modified here, we've got another C which is for catastrophic hemorrhage. Basically, people that are passionate about trauma have decided that a catastrophic hemorrhage is gonna kill you faster than a blocked airway will, which is why you look for on the floor and for more. So that's uh your chest, your abdomen, your pelvis and your long bones. So that could be your femur, it could be humerus. And what you're really looking for in a catastrophic hemorrhage type is you can't really do anything about internal bleeding. That's significant. Unfortunately, it is what it is. But if you've got external bleeding, so for example, you've got a big laceration sort of in the chest or the abdomen or maybe coming out as an open fracture, for example, and you're just hosing blood out, apply external compression. Ok? So just squeeze that first, we'll get to that in more detail later. Then the rest of it is really a bog standard A two week for those of you that aren't familiar with it, I'll go over it properly. So that's airway and in this one, it's also including the C spine, which is again, another modification of the normal A two week, you're gonna do basic maneuvers, adjuncts, intubation, uh an emergency crico thyroidectomy, uh which is basically what the EC stands for. And then the C spine bit is where you do your triple block immobilization is the term that everyone seems to use. Uh you can apply a hard collar, but that's sometimes not everyone's trained to do that and not everyone's comfortable and sometimes it's not available. But what most people are able to do is sort of put blocks on either side of the head and then put tape either side. So you tape the chin and you tape the forehead and that way they're unable to move their head. And that just in case they've sustained ac spine injury, immobilization will prevent them from f, from them, either causing any further damage or from us or people that are moving them and assessing them and transferring them to cause any further damage, moving on to b pretty much self explanatory breathing. So you'll check their rations, you'll check their respiratory rate, any signs of cyanosis, how their breathing is, how their chest wall movements are. Whether or not they've got a pneumothorax or hemothorax, sometimes A1C is gonna be your circulation. So that's BP, hemodynamic, basically status. Uh if they're tachycardic, if they're clammy or sweaty, uh if they're got a decent time or if they're struggling to maintain the volume hypotension, if we become academic about, it can be due to any number of reasons. But in the, in the concept of trauma and in the context of trauma, it is assumed it is due to hypovolemia and that's due to blood loss just for simplicity's sake. So that's really why we, what we think about when we see a hypertensive patient, immediate fluid resuscitation D is for your disability and also diabetes. So your BMS don't forget. So you assess the alertness at a pre hospital setting. So when the scenes often happened, not everyone's able to calculate a formal G CS due to whatever the nature of the trauma is at the time. But you can do a basic a po so that's whether they're alert, whether they're resp response to voice or response to pain or they're just completely unresponsive. You can also then either do a GC SS at scene if you've got someone there that has time to be able to work that out and properly and then do a repeat G CS later, uh whether or not their pupils are equal and reactive to light. So that's what pearl stands for. And then obviously BMS. And then last thing is E which is exposure, fully exposing the patient during your primary survey to make sure that you haven't missed anything else. Because you can imagine for the sake of keeping them warm, often these patients are gonna be quite cold. You will live also to protect their modesty, you'll cover them up with a blanket often. Um And you might miss some injuries that previously weren't available that weren't obvious, you know, the, the most obvious one that you'll get in sort of ays to emphasize this point is you've done a beautiful a toy. Um But on the E bit, you didn't really expose the patient and you realize that whilst you couldn't see any obvious hemorrhage, they're actually bleeding from their back passage or from their vagina, they're a female, for example, and you'd only get to that if you properly expose the patient uh and then other parts of. So the everything else bit is taking their temperature, warming them up where you can and identifying any other injuries, especially near the back because most of the patients will present to you supine. And uh you'll need to then get members of your team to log, roll them once you're happy with the c spine being stabilized and uh assess any injuries on that back, that might not have been obvious that's really a primary survey. So going into detail because that was a brief overview of everything. So the catastrophic hemorrhage, the whole point of this is to identify bleeding, like I said, and you wanna apply the direct compression, which I talked to you about. Now in that sort of setting, you can imagine that trauma you wanna be as efficient as possible and you want to use up as little as your of of your valuable team members as possible. If you've got someone that's applying direct compression to something that is externally compressible, then that person's pretty much taken up because one hand or two hands, sometimes if you need to put some proper pressure on it, uh means that that team member is now out of action. So the other way you can go about it is using the tourniquet and the one specifically in trauma situations that we, well, I say most of the major trauma services here in the West Midlands and surrounding areas has, is something called a combat uh a applicable tourniquet. I know them as cats. So they're orange, they come in different colors. I think I've seen them in black as well. And what really you do is you apply them around or proximal to where the er uh injury is. So where the patient is bleeding out, just proximal to that apply the tourniquet and then you can use this little lever thing here. You guys can see my mouse. So this thing here you just twist or get around and round and round. And what that does is it just continues to compress and compress and it just locks in place. And that, that does is that tamponades and it frees up that member to then do other jobs. And that's essentially what this is and you can have several of these sometimes on all limbs depending on what the trauma is. Other things you can do is for example, a pelvic binder. So the other thing that we're able to do is if we do suspect an internal sort of bleed are in and around the pelvis or pelvic fractures, for example, big motorcycle accidents and things like that, you can put a pelvic binder on which I'm not included in here. But it's another way of and a similar sort of mechanism to this where two people put it on and then you just compress the pelvis together and that in a way acts as external compression to prevent any further bleeding or at least slow it down and take it from there, moving on to your airway and new sea spine. Excuse me. So, the first thing you wanna do is you wanna secure that sea spine? Ok? If you're suspecting an injury, if it's a massive injury, any sort of mechanism for trauma, you wanna think about the C spine. So that's putting on the triple block immobilization straight away, taping them up ensuring that they're in good position, they're able to uh breathe the thing with a patent airway you wanna listen for is snoring or any sort of wheezing. There is snoring, then there's at least a partial obstruction is what's assumed, try to open the mouth, don't stick fingers in there, trying a torch, see if you can see anything obvious and use some forceps to try and take it out. If it's anything deeper, then don't do anything further because you will, unless you've got specialist training, especially at an fy one level, you wouldn't be expected to do anything more than that apart from just to identify things. Uh if it's deeper, then it becomes a surgical uh problem and it will be dealt with later. There are other adjuncts that we can do at that point moving on. So the simple maneuvers, like I said, so the things you'll be familiar with are jaw thrust and head tilt, chin lift. If your C span is immobilized, you're gonna struggle to do that. So you can do that a bit as much as it will allow. But generally you sort of tend to stay away from it if it, if you can help it. Uh, with regards to airway agents that you can do. So that's things like nasopharyngeal airways or oropharyngeal airways. And you can also put the eye gels in and that's really just to help, uh secure an airway if you suspect that it's not being maintained. If, despite all of that, it's not working, your third line really is to start intubating. And uh you can use it under direct vision, uh using a laryngoscope and put a tube in. If you can't get the tube in, then you need to proceed to what we call a, an EC which is this. So on your neck here, you'll have two little bumps. Is that what I like to call them? So, one's your thyroid process, one's your cracker thyroid process. So that's just distal between these two areas. You'll find a little sort of soft fleshy part that you can press. And that's the cricoid cartilage here. So, well, the cartilage. So this is the cricoid process and the thyroid process up here. So this fleshy part is what you're able to press. And this is the part that then you'll need to make an incision is as fy ones, you're not gonna be expected to do this, someone else will do this. But having an appreciation and awareness of what's going on will make all of this a lot less daunting when you're seeing it uh for the first time and sometimes maybe assisting. So someone will make an incision, you might be asked to retract, similar to how this person's doing it here just to help open up that airway. And then there's a basically a cri kit which has all of these things that will have a catheter, it'll have a tracheostomy to you. And then this gets sutured on outside the skin and then that becomes an airway that, that will essentially save the patient's life and allow you to carry on and uh get on with the rest of your A two E breathing. So you're gonna get basic obs set up first. So stick on a sax probe, put a respiratory rate, um monitor and uh basically to carry out a resp exam regardless of, I mean, in contact in an osk setting, no matter what their saturations are 50 m, non rebreath mask, that's what you need to do. Um because you're not gonna do them any harm in a trauma setting. Uh Even if they don't necessarily need the oxygen, and then you can just carry on and see on the monitor if that SATS is improving or not. And then respiratory exam is listening to the chest, looking at tracheal deviation, uh looking for air entry and your chest wall movements. You wanna, if they've got a flail chest, for example. So if they've got rib fractures, um that essentially means that part of the chest is no longer moving. And there's a paradox called seesaw movement and that becomes a bit of a, that what that is an emergency. And then uh if you're having the, the things you really, really wanna be worried about in, in breathing is tension, pneumothorax or hemothorax. Because in that situation, you need to put a life saving intervention which is needle thoracostomy. Uh Well, needle decompression followed by a definitive thoracostomy which is test che uh chest tube uh insertion. Now, I mean, I've, I'm not even that far from medical school, but back when I sort of learned about this, it used to be the thing that if you had a tension pneumothorax and on the side where the tension pneumothorax is you do uh you'd insert a cannula, usually a white ball cannula in the second intercostal space, mid clavicular line that's no longer recommended. Um because cardiothoracic surgeons uh said that it's too high, a risk of damaging internal structures there. The main one really that runs here is your internal mammary artery. So what the best guidance now is is if you're gonna do a, whether you're gonna do a chest drain or you're gonna do a needle decompression, you're gonna go in the same area as you do with chest strain. Does that make sense? So the second in the costal space mid line is not recommended anymore. You go straight for this triangle of safety which is made up in. So it's in the axilla, it'll be on the side, the IPs like the same the pneumothorax. On the left hand side, you're gonna go on the left hand space of the IPSI lateral side. The anterior border is gonna be made up of your posterior border of PEC major and then the posterior border is gonna be made up of the anterior border of black doy. Here, it just says lateral but different textbooks vary. And then your horizontal line is your, it's the top of the fifth rib. So your fifth intercostal space basically. And uh what you're gonna do is you're gonna go over the rib because what you don't wanna do is go under it. And what happens then is you risk damaging the uh intercostal bundle. So that's your nerve, your artery vein that runs just underneath the rib. So that's why you go over the rib. And it's just a simple incision over that area followed by blunt sort of di well identify, make an incision, then blunt dissection. So that's using scissors, opening it up and then using your fingers to sort of stick, stick around there and get into the pleural cavity. And uh then you insert your just tube and it should either hose out with blood if it's a hemothorax or it will just refill and bubble with air and then you know, you, you've, you've, uh you've sorted them out again as an fy one in a trauma setting, it's really unlikely you guys are gonna be expected to do it. But as you sort of come up and depending on where you go, you might get the opportunity to do it if you're feeling a bit more confident. Um So it'd be one to just be aware of moving on to circulation. So, again, hemodynamic stability BP and heart rate are your main things that you're looking for here. You wanna make sure that that BP is cycling as well because you don't just wanna be looking at static BP thinking that's completely fine because when you're, unless you've set that cycle and it's not refreshing automatically. If you have to ask someone, they run the risk of forgetting to ask them when all other things are going on. If that makes sense, we will look at capillary refill time as well. Cos that will give you an indication of how their peripheral perfusion is go is going on and also try and feel for their pulses. And the main thing really you're looking for here is strength. How palpable is it, is it bounding? Is it very thready? Is it weak? Um Is there any radio radial delay, for example. So, and you also wanna establish access. Now, a lot of the times before the patient really gets to you in recess access will have already been established but if in the instance it's been quite quick or they just, they haven't been able to find anything, then you wanna ideally get two wide wall cannula. So that's your oranges and your grays. If you're still struggling, maybe you can go down to, to sort of green but anything lower than that. And really, it's not gonna be suitable. You need to push fluids, you wanna push blood, you wanna push products fast through this. So that's why white ball is, is best. And at the same time, you wanna be taking bloods. So before you flush that cannula, you wanna take all your major bloods that you need. So let's see, the F BCE L FTC RP lactate as well. Take a VBG sample, send that off, you'll get those results back before those bloods come back, take a group and save and send it off for cross matching in case you need to go to the theater. So those are really the, the things you think about in the trauma setting. And then I've said here IO So if in the instance, for example, you cannot establish uh venous access because they're so peripherally shut down, they're really cold, they've lost lots of blood. Um You know, they've not eaten or drank anything all day, for example, and now they unfortunately have been dealt with this trauma, then you'll need to do an IO uh insertion, which is again, it comes in a kit and all it really is, is a, is a fancy drill with a very small sharp choker attached to it and you can either sort of go in the shin so in the tibial bone or you can go here in the shoulder. Those are your two main sites. And what you do is you just drill in as far as this will go and then detach from the drill, take the Stroker out and put a little cannula in that will go in and just flush it like a normal cannula. It won't have the same uh flow rate that you can achieve with obviously the venous cannulation, but something is better than nothing in that situation. And at least you can get something in them and then replacement. So, like I said, for any hypertensive hemodynamically unstable patient, you assume it's due to volume loss. So you wanna replace the volume that they've lost with volume that you have. And we're not really uh crystalloids aren't really the first line thing anymore if you've got blood available, replace blood with blood. So and then I'll put here a 1 to 1 to 1 ratio. So for example, if you, you wanna give a unit of blood, you wanna give that with a unit of F FP and a unit of platelets if, if needed, for example, but really, it's, it's the blood that you need to get in them first. And of course, if you are struggling and you don't have access to blood or it's not coming fast enough, then crystalloids are the next best thing. So that's pretty much circulation moving on to disability. So this is just your standard G CS. So on arrival, if you don't have a G CS, you wanna work one out. So eyes, speech and motor for those of you that aren't too familiar with it. So the way I think about it is work my way upwards, rather work my way down. So the lowest G CS you can have is three. You get one. If you can't open your eyes at all, you get one. If you can't talk, you're not responsive and you get one if you don't move anything. So for your motor and then the next way up for eyes is similar to sort of au so you open your eyes to pain. That's two. You open your eyes to voice, that's three and you just open your eyes. That's 44 marks for speech. So nothing is one sort of groans and grunts and sounds. That's true. Uh If you're making words, but they're incomprehensible. That's three. Um, four is more, um, confused type of speech. So most patients, they're able to form sentences, talk to you, but they're confused, they're not orientated. So that will get you four and five as, as they're talking, normally they're able to respond appropriately to everything you're saying, then they'll get four marks and then for motor the way it works out is, one is where, again, nothing, two is two and three are a bit odd. So the way, uh, you wanna do this, so two is where you get abnormal extension and then three is abnormal flexion. And the way I remember that is extending yourself to pain is, is odd and it's worse than flexing because if you flexed the pain then that's protective. You're protecting and you're recoiling yourself from any further pain. So that's why that's a bit better. You must have all kinds of damage. If someone's inflicting pain on you and you uh abnormally extend and in a way are saying come, give me some more, right? That's just a stupid way of remembering it. It worked for me. So, abnormal extension is two, abnormal flexion is three, then it's um so withdrawing from pain and uh localizing to pain. So, withdrawing for pain is if you inflict pain and you don't really take your hand away and push it, that's five. If you inflict pain and you sort of just shuffle your shoulder or try and get away from it, that's four. So withdrawing is four, getting your hand and actually taking the patient that examine his hand away. Um That's five and then six is you have to follow commands. If you ask them, squeeze their fingers and they do it. That's six. That's G CS in a nutshell. So, like I said earlier, most prehospital settings are gonna assess AF U. So before they come into the hospital, so you'll get an idea as to where they are on the scale. G CS of sort of less than eight is considered mainly unresponsive in most situations. That's where you're thinking about whether the airways is gonna be compromised, whether you need to think about intubation or an or an emergency cry. So then when you do your initial primary survey, so you get to this bit. You wanna do your G CS, make sure someone's noted that down. And then later when you get down to your secondary survey, which will come on to, you wanna repeat your G CS and see how they're getting on. And if there is sort of a deterioration, you know, obviously, we hope if there's an improvement, we're on the right track, we're doing well. If there's a deterioration, that's a problem, you might need to think about getting them quicker into the scanner or maybe just phoning the neurosurgeons because something's going on up here and then imaging which again, we'll go on to, don't forget BMS. It's notorious, but D it should be disability and diabetes. So don't forget the blood sugar and then exposure, which I talked about a fair bit. So fully expose them, check for any bruising, especially around the limbs, which would be covered most of the times, especially the legs. Uh You wanna check their temperature if they're cold, you wanna think about warming? So we will have been most of the time warming them externally, but we can give them warm saline, for example as well. And sometimes the blood can run through a machine that warms the blood for them. And that in a way is an internal method of warming them up. If there is a, you know, for example, really, really bad intraabdominal wound that exposed, you can, you can put warm saline in there, do a peritoneal lavage for example, but you as an fy one will not be doing that on your own. So don't worry and then log rolling, that's the other port er important part. So get your team together. Once you're happy, you've done a primary survey and you've sort of done all the important bits up here that need to be done first, then get to ro log rolling, make sure someone's held their c spine in place and everything is good, turn them over and then see if there's anything you missed on the back. Look for bruising, especially on the back because retro retroperitoneal injuries. So things with your kidneys, things with um your pelvis, uh just generally internally intraabdominal bleeding ovaries, for example, uh that can all sort of amalgamate in bleeding Retroperitoneally, which will manifest itself in the back because you're gonna be supine. So all that blood's gonna be pooling in the back. And so you'll see some evidence of bruising or tenderness if they're alert enough to tell you and that's just, well, that's just how people are log rolling. So there's uh one guy or person that's gonna be supporting that head, there's a few people that are gonna be around pulling the, the patient towards them and the examiner, you, if you're doing the primary survey is gonna be here and then looking at their back and you're gonna feel all the way along from the back of the head, see spine, thoracic abdominal lumbar spine and um then just down so that cox the pelvis region uh and actually, whilst they're being log rolled, sometimes it's a good, good uh opportunity to perform ad re um but that's again, more party secretary serving. So bring this on to the secondary survey. Does anyone have any questions at this point before I just move on? Um There aren't any questions in the chat at the moment, but I'll let you know. No worries. Awesome. So secondary survey start off, head to toe basically. So you've the, the point in the secondary survey is to go over anything that you've missed. And also between the primary and the secondary survey, you will have made some initial interventions to deal with the C ABCD E that you've done in the primary survey. Cos those are the things that are gonna unfortunately kill the patient first. Once you've dealt with those do the primary survey, cos now you're thinking about longer term planning, ok. This patient isn't gonna die imminently. Now, I've got some time. Let's see what else they've got going. That's wrong with them that I will eventually need to deal with down the road and start making a plan as to what specialties we need to involve, who needs to take this patient to theater first, for example, who really needs to be involved with this patient straight away. So start at the head. You wanna look for things like lacerations to the scalp. You wanna look for um damage to the eyes. If they've got some bruising some ecchymosis, if they've got orbital pain, if they've got problems with their eyesight, um If they've got nasal trauma, their nose is broken, they're bleeding from their nose. If you can see that they've got some kind of locked jaw, for example, or just an odd face, um uh or like some blood coming from the ears. Those are the kind of things we need to think about that would alert you to whether or not you need to get max fax involved, ent involved or indeed whether or not there's a high suspicion of a neurosurgical emergency going on, moving on to the c spine. We've talked a great deal about that really. But during the log role, it's a really good, good chance to have a feel of all the uh spinous processes. If you're pretty much happy, they'll still be immobilized and make sure that someone is always supporting the head when they're out of blocks and when they're not being supported, put the blocks back on and the tape back on. Because until they've had imaging, you cannot confidently clear that c spine from any unstable injuries. The last thing you wanna do is take that safety away and then you've dealt with everything else and all of a sudden they damaged the spinal cord up here thorax. So you will have dealt with this a lot in, in the B section of your primary survey. But this is really now giving you a chance you've dealt with the immediate threat, which is your pneumohemothorax. You might have put a chest strain in, for example. Now it gives you a chance to look around the chest, look for any evidence of bruising, look in the axilla, for example, have you missed anything there, is there any other small sort of lacerations that might need stitching? For example, is there some muffled heart sounds? For example, um that might be a problem later down the line, you might need to involve the cardio thoracic surgeons. So that's really what the thorax revisiting thorax is about similar to the abdomen. Again, you wouldn't have done a great deal of the abdomen in the primary survey, you probably would have picked it up when you do your exposure, but then coming back. Now you can do a proper abdominal exam if they've, if you've done your interventions between your primary and secondary survey. And this patient is a lot more Rous. Now, they might be able to tell you if there's pain, if you press on there. Do they have bowel sounds? Are there any masses? Can you feel any organs? Are they tense? Is it rigid? Um, those are the sort of things you're going for there? You can also look into sort of their genital and groin regions. Let's see, a pelvis perineum. Is there any bleeding, particularly if there are a woman, for example, were they pregnant and they were involved in a, in a car crash? Has there been a potential miscarriage? Is there damage to the baby? Are they bleeding from the vagina? For example, that would warrant than a vaginal examination? If they've got some rectal bleeding, you need apr exam if you're worried about, you know, if they're a bloke and they've um got a pelvic injury, is there blood at the meatus of their penis? So those are the sort of things. And if you're worried about a spinal cord injury, do they have sensation around the perineum? And uh on, on your pr exam, do they have anal tone? Are they able to control the, the anal sphincter? Those are things that will point towards uh one or the other and help for the management plan. And the last late is your limbs. Arms are pretty easy because most of the time they are exposed and because you're trying to get venous access in, in them on either side mo these guys will get a pretty good look at legs unless really, uh, you've been told by the prehospital that this is the injuries that this is sustained once they're covered in a blanket, unless you've exposed them in the primary survey and you're actually seen, uh, you know, there's something you need to come back to in your secondary survey, they might get ignored. So again, re expose the patient and have a good proper look at their lower limbs, make sure that they've got a normal sensation throughout those limbs. Make sure that they can move those limbs. If it's possible. If they've got a pelvic binder on, then you wanna think about maybe releasing the binder a little bit if you can or doing what you can with the net. Are they able to wiggle their toes? Are they able to move their ankles? Is there any deformity? Is there any swelling in the knees or the back of the knees and the back of the legs? So those are really the things that you wanna be looking for, make sure you've got a full range of movements. If there's an obvious fracture, then that's something that you need to then add on to your management plan. That's pretty much your secondary survey. Once you've done all of those things, then you go on to the trauma history. So if this patient is, is aroused is if, if they're, if they're awake now they're no longer unconscious, you can then talk to them and in a trauma history, it's not, you don't have time and you don't have unfortunately the opportunity to be able to ask them about every single thing. So the key and pertinent things that you need to do for a trauma patient that might need to imminently go to theater is using this new mo called ample. So for those of you that don't know what PL is a, is for allergies. So the main really thing is penicillin, are they allergic to penicillin or any other medication that they might be given? Then it's the medications. So what medications are you taking? Especially the tri time critical ones and the ones that, you know, for insulin I put here anticoagulation or you know, that ha need to balance out their bleeding risk. For example, antiplatelets and anti anti hypertensives as well. Have they taken any antihypertensives that are artificially bringing down their BP? And we're just pumping them full of fluid right now. Uh, and time critical medications that need to be prescribed no matter what, even in a trauma setting, patients with Parkinson's disease still need their Parkinson's medications. Patients that are epileptic, still need their epileptic medications. If they're not in a state to have it orally, then think about what other things that we can do to give to deliver it. So whether that's intravenous form or if it's some sort of solution, then we need to sort of look into that, then it's past medical history. So that's also past surgical history too. So if they're able to tell you, or if you can get up their GP records, for example, or if there's a family member that's accompanied them and the patient themselves can't give it to you, but you can get collateral history from, from the family member. And that's really the, the way to go and then when they've last eaten. So this is purely for a for an anesthetic point of view. So when you are inducing a patient and you need to take them to theater, there's a risk that if they've eaten something, uh there's a risk of aspiration later down the line. So whether the nieces need to think about a rapid sequence intubation or they haven't eaten or we can maybe push the surgery until the point where there's been enough time that they will have been no by mouth long enough to then safely be taken to theater. That's quite important. And then lastly is the event. So this is more mechanism of injury. So what events led to them being presented to you today in hospital? So what were they doing? How did they sustain this injury? What went wrong as much things as they can remember, witnesses get some collaterals if you can. And really the mechanism of injury is the most important thing because what you want to know, especially for example, traumatic car accidents, motor vehicle accidents, if they were in a car, you know, did the airbags go off? How fast were they going? Were they wearing a seatbelt if it's, uh, a patient that was driving a motorcycle and they went over, uh, often a lot of the protective gear might have already been taken off prehospitally or by the time you get to them, uh, they won't have their helmet, for example. So, was the helm, were they wearing a helmet? Were they wearing protective gear? Did the helmet um get damage? Is it cracked? For example, that could tell you a thing or two about just the sheer force of impact and what their body will have gone through. So those are really things uh to think about and then trauma imaging really. This is this a bog standard ct everything. So CT head, CTC spine are the main two things. And then ct thorax ab and pelvis, honestly, by the time they're done, you want them to be glowing in the dark? Uh And then the last thing is trauma imaging. So that's that. So you everyone pretty much gets act head c spine and act throughout A and Pelvis. But if they've got, for example, limb injuries, if you're suspecting a fracture, then you might throw in an additional X ray of the area, the joint above and the below, for example. Uh so that for uh to you know, when, when we come around, then were able to just get on with it and make a plan. So that's pretty much a whistle stop tour of everything you need to know. I know there's a lot of information. So, what I've tried to do now in this part is, uh, do a recap. So it's a, it's a worked case and I've simplified it from a case that I've been involved in not too long ago. I'm hoping that a few of you can just get involved and uh see where we go from there. Is that all right? I think Maria might need to help me on this. Yeah, sounds great. Um Guys, yeah, if you just type answers in the chat and then I can read them out. Oh, so you're an F I one doctor in A&E you're holding a trauma ca crash bleep. So you're part of the trauma team and it goes off, you're not gonna run the trauma call or anything, but you'll be part of the team that responds when the trauma arrives. Ok. So here's the case. You're a 27 year old male. Well, the patient is a 27 year old male, road traffic collision. They came off their bike at about 70 miles an hour and they're coming in via an air ambulance. So the trauma team assembles in recess. So normally that's the anesthetist, the trauma team leader, which is mainly an A&E consultant yourself as the trauma fy one. Uh in uh there's a couple of middle grades around, uh, general surgical registrar will come, the orthopedic registrar will come and those are pretty much. Oh, well, anesthetist as well. And, uh, the, I mean, depending on where in the country you are, if you're in a major treatment unit, then, uh, sometimes the neurosurgical group trial can also be bleeped and come as well as cardiothoracic and plastics sometimes. So, the T TL, the trauma team leader will in this situation, he assigns you as if I want to say, ok, I want you to form the primary survey which is a, a bit brave. I don't think you will be in this situation. But if you ever are, if you're in a small little D GH, like I was from Fy one and Fy two years, you might end up doing this. So the pre hospital team come and they say that this patient was unresponsive seen. Um They were wearing protective gear, their helmet was cracked on scene. They haven't brought the helmet with them because it was just too damaged and not worth bringing it over and it was deemed dangerous. So they left it there at the site. Um, but it's been recovered by police. We don't have access to it, but all they've got are pictures and they show you that actually it's, um, it's been so severe that a, a massive hole sort of formed through it. Um And it's in pieces. So primary survey, someone take me through the primary survey or guys can just type and Maria can tell me what you guys are doing. So, how are you gonna do this? What's the first thing you're gonna look for? I'm just gonna wait for some answers in the chat. Yeah, no worries. No. So they said catastrophic hemorrhage first? Nice. Ok. So in a catastrophic hemorrhage you're gonna be looking at, um, yeah. Uh, four on the, well, the F four on the floor and four, what? Blood on the floor and four more? Sorry. Uh No significant hemorrhage noted. And you made sure you exposed and everything. So that's fine. What comes next? We've got check the airway and see spine nice. So they've got snoring, groaning sounds and their c spine has already been immobilized in a triple block. What is next? Breathing? Yeah, cool. So that's the saturations on room air and that's a respiratory rate. They've got reduced breath sounds on the right base and auscultation and they've got left sided tracheal deviation. All right. So not gonna give too much away at the moment, we'll move on in the interest of time. So see you guys pretty much know we just go see ABCD E from this point on. So they're hypertensive significantly and they're quite tachycardic. Ok. So that already tells you they're quite hemodia to be stable and in a trauma setting, our number one assumption is they just lost a lot of volume. Ok. So that's the cause the refill is uh prolonged significantly for seconds. That's quite a long time. So we know that actually the tissues are not getting adequately perfused and that fits with the hemodynamically unstable picture, but the heart sounds are normal D so the G CS is seven out of 15 eyes are one. So that means that they're not opening them even to pain uh SS too. So like I said, they were making those groaning sounds. Um But they're not words, you can't really comprehend what those are. And M four, which is what I said earlier. So remember that six is completely normal five as if they can localize the pain. So if you pinch them and they get your hand and push it away, that's localizing or as you pinch them and they're sort of trying to roll away or something like that. So they're withdrawing from pain. So that's their and then BMS 6.2. So nothing really to write home about. E. So in e you noted that they've got bruising in their right flank and in their axilla with a dull percussion note in their right anterior chest. Uh they've got abdominal tenderness in the right upper quadrant with the gray turner sign in the right side. So that tells you there's some retroperitoneal um bleeding going on somewhere in the right side. So think about your retroperitoneal anatomical structures that might elude to this in the right upper quadrant region and then a swollen right, lower leg with a deformity, mid tibia, surprise, surprise, who knows what that could be? Right? Uh Fine. So that's your primary survey. So then after you do your primary survey, you need to feedback to your trauma team leader as to what you feel are the initial injuries based on the uh findings of your primary survey. So if I've put that deliberately here for you guys, so based on what you've got here from the primary survey, just it probably easier to type out. What sort of injuries do you think this patient has got right now or what sort of things initially that you feel like you need to deal with? And then Maria, you just let me know. Yeah, we'll just wait for them to um Yeah. Yeah, the responses. So we've got um to address the partially obstructed airway. Yeah, that's one of many things. Anything else guys? Uh We've also got a couple of uh tension pneumothorax responses as well. Nice. What side do we think that's on? Uh People are saying? Right. Yup. Cool. All right. Any other things. So, so far we've got partially instructed airway and attention pneumothorax on the right hand side. Um and also the retroperitoneal hemorrhage. Nice. Ok. Anything else this is Ortho are plastic? Lots are checked. Anything with the lower leg that guys this bit here. What kind of injury does that make you think? We've got tibial fracture? Yeah. Awesome. Thank you for whoever put that on. Right. So, yeah, query airway instructions partial because it's snoring. Query c spine injury because there were motorcyclists that mesh mashed up their helmet at 70 miles an hour. There is no way in hell, they have just walked away from that. So until you've imaged this, that is ac spine injury that is unstable and is not coming out of block or at least a support until otherwise proven that it's stable. All right, well done guys, it's either a right sided pneumothorax or a right sided hemothorax. Because again, those are the two things that might be going on here. Given the fact that they have dull, sounds on that right side. So this thing dull percussion at right side, anterior chest and the hedon be unstable makes me think it's gonna be more hemo pneumo hemothorax rather than pneumothorax. But we move intracranial injury because again, they mashed up their helmet and they've got a G CS of seven right now. Intraabdominal injury. You guys had a retroperitoneal injury, which is acceptable. So yeah, all of this down here and then yeah, uh fracture right tip fib. We, we don't know where but in that region. All right, cool. So those are your initial injuries that you fed back to your T TL. OK. So the trauma team leader instructs interventions for you guys to perform, OK? For the the team to perform, not just you. So in terms of your initial interventions. So what are you gonna do to deal with all of these c spine is already sort of dealt with? You've immobilized them. So that's fine. What else are you gonna do? Give you a clue. There's not really much you're gonna do for the intracranial injury. It is what it is at this stage. There's not really much you're gonna do for this either. All the rest. So really what, which one of these is gonna kill him imminently? Um We've got an answer about the airway where they'd want to consider intubation or adjuncts. Yeah, fine. So initially to mention that you're gonna do for everything. All right, oxygen. So 15 L, non rebleed mask. Remember back here, I told you that uh they're on room air. Yeah. So stick him on a 15 L non rebreath, high flow oxygen. OK. Airway adjuncts is right. So you wanna improve their airway sounds, you wanna remove any obvious foreign body. If it's present, don't stick your fingers in there, use forceps. If you can. If there's anything further, then you might need to think about intubation or emergency. Er Rike keep the patient in that triple block until cspine imaging has been cleared. I cannot stress this enough uh continuous cardiac monitoring and cycle that BP continuously. All right, this is the thing I was trying to get at. So this is gonna kill them. So once you sorted their way out, it's partial obstruction it's not full obstruction. So it's a judgment call. But as long as your trauma, team leader is happy, you can live with that for a little bit, maybe stick a airway in there fine. But this is the thing that's gonna continue to get worse and it's gonna get worse quickly. You're already at a stage where there's tracheal deviation, that's quite a late sign. So, what you wanna do is get a needle decompression in there at the very least, followed by a quite quick uh, chest strain insertion uh in order to relieve that strain on the patient and their cardiovascular system that's gonna save their life. Yeah. Sorry. I think someone did actually comment now, I just missed the comment but um I was on a rouge. Sorry, I missed your comment. Cool. And er, yeah, you wanna get IV access bilaterally. Those are the wide wall cannula. You wanna get bloods of E BG, like I said earlier, you wanna activate the major hemorrhage protocol? Cos actually this guy's really, really unstable. You know what I'm saying? He's a young guy, he's come off a bike really severely. He's really, really hypertensive and really tachycardic with attention pneumo or hemothorax that we don't know. Right. So safe to say he's definitely gonna need some blood. And along with the major hemorrhage protocol, you'll get uh F FP and you'll get some platelets with that as well if you ask for them and don't forget analgesia this guy is gonna be wailing in pain. If he comes around, he's gonna just go straight back out, give him analgesia even if he's unconscious. Ok. And then you wanna check response to interventions. All right. So lo and behold his SATS improve on 15 m non rere mask, his respiratory rate comes down. So he's no longer tacked ne as much. He's not that much distressed in the needle decompression, blood comes out of that cannula. So you then follow with a chest drain insertion and that drains about 800 mL initially and it's all blood. So you know, it's a hemothorax that happened once you sort all that out. Their G CS magically improves to 13. Alright. They're talking now they're a bit more confused, they're opening their eyes to pain and uh they're moving their arms and limbs if you tell them, oh, squeeze my fingers, they will squeeze them. So they're able to process information, they're able to then execute the instructions the heart rate has come down. So that looks a lot better and the BP has come up V VG has come back. So it shows that they're a little bit on the acidotic side, but still within that normal range. Uh P CO2 is on the lower side. Po two is a bit higher, especially this is a venous sample. Um But again, they're on a lot of oxygen. The bicarb is really, really low for what it should be. You'd expect that sort of be sort of hovering. The 22 upwards HB is quite low 79 which is why it's good that we're transfusing and the lactate is really high, which is in keeping with the fact that they had a prolonged um capillary refill time. They had really low BP earlier. They had really high um heart rate to compensate for it. So what's going on is their tissues because they weren't adequately being perfused, they go into anaerobic respiration, therefore, increasing lactate production and that's driving the lactate up. So the tissues are really starved of oxygen right now. So keep the oxygen going, keep the blood going and it should hopefully improve in serial, the EB GS that you take later. Awesome. So those are your response to interventions. So your initial resuscitation has been achieved, the patient is a lot more stable now, they're not dying in front of your eyes. So the trauma team leader now asks you to proceed. So what's the next step you're gonna do? You've done your primary survey, you've done your initial interventions, you've checked for the response to those interventions. What are we doing next? Secondary survey? I've got Yeah. OK. Yeah. So we've got secondary surveys. So again, like I, like I mentioned earlier in the slide. So from a head to toe, what uh if I if I take you through what your secondary survey is gonna be? So you examine the head. So you're gonna find multiple superficial scalp and facial lacerations. There'll be some bruising on the right orbit but their pupils are equal in reactor to like bilaterally. OK. What are you doing next? From your head? So I've given you the first thing. Uh we've got c spine. Yeah. Um OK. Yeah. Uh we'll come back to that, but fine, I'm just gonna co we're, we're, we're gonna overrun. So I was just gonna carry on. So we've got thorax. There's no significant chest wall tenderness. The b breathing sounds have improved. The chest drain is bubbling. So that's good. It means that air is now moving freely. It's not just pure blood. So that's OK. You move down to the abdomen pretty much the same findings are there, but it's worse. Now, you know, there's tenderness, there's guarding. Patient is now awake and is able to sort of tell you a lot more. Um You can't hear any bowel sounds and there's right sided bruising around the flank still and I forgot to write, but it's a lot worse. They've got significant pain in their right lower limb around the swelling in that mid tibial region. Their pulses, that's the posterior tibial and the dorsalis penis pulses are palpable bilaterally. Um But they're reluctant to move due to pain even though you've given them 10 mg of IV morphine. So, uh yeah, then yes, like someone said, quite good was the C spine. So you do a log roll and you wanna check all of their spinus processes along, you can't feel anything on the back. The spine scro is completely fine, so no tendons there. But you can see that around their lumbar sort of flank regions, some sort of your lower thoracic mid back region, they've got bruising around their right flank, sort of extends right down to the midline of their back. So there's definitely something going on there. OK. And that's really a secondary survey. So now that you've got all those findings there, what images are you gonna wanna request? Um Someone's put CT tap and I guess for the sake of time also CT C spine and um C so don't forget about an X ray of the uh right knee, the right tip fib the right ankle because you're worried there's a fracture there as well. OK. So, yeah. And also, like I said earlier, um they've got scalp and facial lacerations, they've got bruising around their right orbit. Um the right pupil. No, that's wrong. Sorry. Uh ignore that that pupils are equally responsive to light. So just this bit bruising around the right orbit that might tell you that actually there might be some kind of facial trauma going on there. Their bones might have the same fracture. So CT head, facial bones c spine, CT tap and then x-ray right knee to fib and ankle because you wanna make sure that you also capture that fracture at the same time. All right, results. So, no intracranial hemorrhage from your ct head, right sided infraorbital maxillary fracture. And this is the thing you need to request specifically for facial burns because actually what ends up happening for the sake of radiation in sparing patients with radiation. Sometimes even in a trauma scan, what they'll end up doing is they'll do act head that. So it sort of comes to down here and, er, once they've gone past sort of you your brainstem and they're fine, they'll stop and they might miss bits here and then they will and carry on the ct it, ask for facial burns as well. And they, with facial bones, they also give you a reconstruction most of the time. And with that reconstruction, you're able to then visualize it a lot better. And then the x-ray right knee, so right sided hemo pneumothorax, sorry hemothorax that's now been drained uh with a thoracostomy tube in situ. So you guys did that stay the patient. They've got right sided fracture of the ribs, right from ribs five down to 12. And they've got a rupture of the right kidney with hemoperitoneum, which is why they've got worsening pain. Currently currently going on, they've got guarding, they've got absent bowel sounds because they're basically in an ileus due to pain and just massive amounts of pressure down here. And uh that also explains the worsening flank bruising. And then they will also on the X ray, you can see a closed viral displaced fracture of the right mid tibia and fibula. So it's both bone fracture but it's closed fine. So, definitive management again, you as the trauma team have done your bit, now you've saved the patient, but now they need definitive management of their injuries. And that is gonna take a varying amount of time and what the multidisciplinary team need to do. And the trauma team leader needs to do is to now triage and see what needs to be dealt with. First, in this situation, you're gonna wanna involve max fax. This is not given in any particular order by the way, but you're gonna wanna involve max fax for the infraorbital, right maxillary fracture. You wanna involve the gen surge regr for the hemoperitoneum and the rib fractures. I'll put that in asterisk, come to that later, urology for right renal rupture TN O for the closed fracture of the right tib fib. And also itu because as patients gone through a significant injury, they've now lost at least one kidney. And uh you know, they're, they're still circling the drain at the moment. So there's, I wouldn't say they're hemodynamically stable yet because they're still tachycardic at 93 and uh hypertensive at 100 and three systolic. So, you know, transfusions are only gonna sustain that as much. But if they're bleeding in their abdomen, if they're taken the emergency to surgery, they're gonna need postoperative, it support. So definitely involve the ITU team and he's young as well. Why I put rib fractures in asterisk because different centers have different teams that deal with it in a lot of places that I've worked so far Genser tends to deal with the multiple rib fractures, but sometimes it does kind of come under TN O and sometimes it comes under cardio thoracic. So it's a bit of a mismatch. You need to look into your local policy and often the registrars will be able to fight amongst themselves. There's an F I one, you don't really need to worry yourself with it, but just have an awareness. Um And that's it in terms of ordering this gen surge followed by urology would be the most important itu are gonna be involved throughout max fax, maybe would get involved at a later stage. But really, once these things are dealt with, then Max Vax and TN O can think about doing their bits um and take it from there. Really TN O probably will come shortly after these two because you're worried in a type of fracture, whether or not this patient might develop compartment syndrome. So you need to make sure that they're pretty closely monitored postoperatively and at the slightest sort of escalation of pain, you uh wanna promptly review them and think about take them to theater and that is pretty much it. We've run slightly over, but we also started a bit late. So thank you. So much guys for listening. If there's any questions, pop in the chat, I really appreciate you guys have your phones with you to just scan that. Otherwise I will get Marie to send you guys a link for this feedback form. It really helps me out, especially because I've got uh applications around the corner. So thank you. Yeah. Um We've actually got feedback forms attached to me so I can send those to you once they. Um So I will put it in the chat now, the feedback form for you guys to fill out, which is through medal and then once you guys have filled that out, you'll get the um the certificates. So let me just upload that. Give me one second. Um ok, so yeah, I've just put the link in the chat now and. Ok. Ok. Let me just double check. Ok. Um Yeah, so if you guys can fill out that feedback and then I can send it to um Mr Asa. But does anyone else have any questions before we end the session? No. Ok. Um There's a QR code as well, which is the same as the link if that's easier for you guys to fill out. Um Just make sure you fill it out so you get the certificate um and we'll update the driver leader board at um the end of the week, but thank you so much Mr Sahu for that great session. Um It was really useful and it was nice to have a case as well. It was um quite fun to work through. Um but yeah, if that's everything, thank you everyone for coming. Thank you again Mr Sahu. Um and see you guys next week. If you are attending our upper limb session, take care all the best. Thank you. Bye.