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welcome back. So before the break, we left for Doris's had a full just to recap she had full in the box. Step on your heads. Find this morning. Lots of 24 or south of 92. Respiratory it of 24. Heart rate of 77. The pressure of 10 1/40 It she she has 14/15 temperatures. 35.2. She's history of COPD hypertension on a F usually independent in her own home, but walks with a stick and she's due in any time Night on. We've decided that she requires a consultant, uh, review just when she arrives. Okay, So how are we gonna approach this patient? Want to see lots of comments coming in this afternoon, then please, Books. So, um, to, as with any trauma, we're going to do a primary survey with a B C D approach. It's the same sequence is a standard drama, uh, primary survey with HDLs principles. Just with a few key additions and silver. Okay, so first of all is our big see your small see received. Fine. So let's see. And the comments there. Well, what do you think? What do you looking for in your assessment of your your small See No takers. Right? So we talked before the difficulty and, um, bicycling these patients with the kyphosis and their spine. So you just need to be careful about the position. The gym mobilized, um, in with something under their heads and not forcing them till I bark, which is forcing their neck into extension. There's a high risk of fracture on. Also, if you needed to, uh, RSI this patient, you know, that was going to increase your risk because you can't move their c spine. Make managing that airway difficulty column has correctly pointed it, um, you want to discuss for tenderness in the neck? Danny's that potentially dangerous mechanism since he's full of her head, Um, you want to establish if there's any distracting injury parasthesia or anything, so will protect your C spine for the time being. She hasn't got any neurological signs, and we know she's bumped. Her head will move on. So living on the A is the airway patient we're looking for features such a slow, uh, noisy airway strider or gardening secretions, facial fractures that does the patient have dentures, but they swelled the dentures. It's more difficult to barbeque patients when they're dentures in, but it's easier to interview with the dentures. Elderly people have kind of loose side. The soft tissues are under their fist. What could be hard to maintain? A seal with a mask that making again intubation difficult in this good. So Doris's Airways patient for the time being even on to be, What features are you looking for? And B, particularly when it comes Teo to silver trauma suggestions. Welcome from anyone? Yep. Thanks, Chip. So you're right. Somebody says we said before these patients chest lows are brittle. They're more amenable to fractures of multiple rib fractures. Um, yeah. Yes. And you want to see you? This the chest rising full bilaterally. So is there equal expansion? Similarly, when you listen, is there any cual air entry? Um, rib fractures. Could be, uh, you could have failed. Failed Chester. A displaced fracture is causing a pneumothorax or a hemothorax, and there's increased chance off elect assists and collapses. She's been lying on the floor a swell on the compound effect of concomitant chest disease that so may have additional times that craps or weasel reduced air entry due to COPD, or infection or effusion, and C CF or some other condition. And once again, I just want to reiterate. Don't assume hype opteem ear is due to COPD or similar. Uh, In addition, you can have hyperventilation due to the injury if the breathing is painful or drugs. So again mentioned earlier, you're checking for opioid patches on things like that, having you look at their medications, feel for expansion crepitus subcutaneous emphysema. Listen because but someone's get it was doing so extended fast with bedside ultrasound to look for long sliding or effusion that could be useful. So in our patient harvest, virtual is 24 salts of 92 a bilateral capitation more so on the right, Just tender over the right side's off her chest. Posterior e and laugh really did okay and looks like it's been a bracing Pam on that. Maybe some subcutaneous emphysema. Okay, so what are our actions? And I based on that bit of the history clinically, what do you think might be wrong? Good. Thanks, Tony. On there, as gently says, Hey, flu or two. I remember that even in a patient with COPD who returns. Teo Hypoxia is gonna kill them before hypercapnia does. So you put on some high flow oxygen, understand? It's improved in 96%. So with that, we move on, See? Factors that we look for and see. Okay. Yeah. So what was the BP? It was 101 over 48 I think. Yep. Goods. Get some IV access and yeah, absolutely sure she's hypertensive. Baseline Should man on the floor, she might not have had her tablets, so you would expect her to be hypertensive. So it's a relative Hypertension? Yes. Nickel hcg, Um, on the subject of ACG. It's important, but it shouldn't distract from the primary survey, and, you know, it's not. It's not a life saving intervention. It can come a little bit later. You know, three lead monitor will be sufficient to begin with, and I can, you know, get in the way of of doing other things. But it's certainly worth keeping in mind that for a couple reasons, that will come on two. Um, so, yeah. Basket access worth considering in the elderly patients that they can have visibly jittery to the drugs they're on. Um, if patients on. Ah, a beta blocker or a calcium channel blocker. They may not be able to mind to tachycardia, which may mask there some signs of the shock. Get IV access and stop bleeding. What do you think about giving some TSA? Is that a yes or no? For T E X A. All right, so in general, uh, no goods. Yep. So the class two trials said that T X ray was a benefit if given within three yards off sustaining injury, where you suspect bleeding is Take this. Our patients heart rate is 77 BP one a 1/48. Pulse is regular with a central company. Fill time of four seconds. No significant external hemorrhage visible. But as we had a bit of bruising on the right hand side on the paramedic or they were on this group of Mr Plaque was her containing ramipril 2.5 picks up on 5 mg on bisoprolol. 5 mg. So does not change your picture of the patient at all. You've been more concerned with any of those medications? Yeah, all of them. Probably. So any other actions? And I What might we like to give to this patient, um, give him. It's his own news. So are you gonna give her fluids stage issue there? What sort of fluids loves? Yeah, so Chris Lloyd doesn't contain any, Um, given it doesn't carry oxygen. It doesn't have any clotting factors. It's completely useless. And drama. Um, last year, literally up risk off losing your right foot. So a degree of permissive hypertension would be alive on, you know, with with Norris's BP as it is, you could tolerate that until you can get blood products. And you might also consider giving her something to try and reverse her Do walk, which it was likely last time last night. Eso you might give TX a given that bit of information on also some architects you can discuss with hematology, but that's probably what they'll tell you. So we'll do that. We've ordered some good grip and cross match, have ordered some blood from the lab, get it at the you know, even a common I was supporter and we move on to the in the meantime. So anything else you might want to do just as we talked about turning off the top, any other interventions might take the time to put on a a pelvic binder. If you're worried that that she's fallen on uh, yeah. Um, check that her legs right. Two lengths and things about good. So what? We're going to D and we're looking for the usual things. CS People's, um gross criminal and peripheral nerve exam. Looking for spinal injuries that you have a stroke that might have precipitated the full. Um, some people talk about a p r n a log roll, I would say. Be very, very, very careful If you're logrolling anyone or even better, Don't know Gralise patients, um, to our patient had a DCs of 14 was confused before DCs know her, I says are open to voice she based commands. And in fact, as time goes on, just localize to pain. Um, confused speech. Pickles are equal and reactive. Midsize moving all four for limbs under blood sugars. Americans is 9.6. So GCSF dropped 12. Get a bit more worried about her as we go along here. Exposure exposed to create patient completely. Um, try and keep her warm because the temperature, um, was a bit low when she was coming in. Try your best to preserve dignity. You know, instead of stripping this patient, dying in front of everyone in recess and look for some general signs of bruising wounds, clinical deformity in the elderly patient has been lying on the floor. Pressure. Ulcers are important. This have a stomach to see if a pacemaker, any dreams or any scars. Okay, so yes, well, Anderson assessment probably comes a bit later, but yeah, it's a brief look, Teo, to make sure that there's there's nothing else. Apartment to your primary survey that needs immediate treatment. Um, our patients has a temperature of 35.2. She's very tender in the right upper quadrant when her abdomen is palpated know external hemorrhoids. But she's bruising on the right side of her chest. Her flank. Um, so anything that needs treatment of the minute Okay? Goods? Yeah. Excellent. So I need to give her some pain relief. We can do that. We're gonna do as we talked about in the palliative care talk to do that cautiously with opioid analgesia. Give several allergies here simultaneously. Now, what about the temperature? I remember when before lunch, we talked about the lethal triads on, um, hypothermia. Good okay? Yep. So builds. Or if you are having to give any fluids for your warmer, I would caution the use off the bare hunger that our patient is on a beta blocker so she can't find the tachycardia. She's also on an ace inhibitor. So if you put the bear hug her on on peripherally visible day letter than purple pressure could, uh, could take a precipitous drop. So lots of blankets certainly prevent it from getting any colder. And I think really passive warming. In the meantime, we're talking about some are junks which includes bloods. See gi on imaging. So no test. We're going to sound the usual. Gamut them off our full blood count coagulation grip on hold Or indeed, across much the routine biochemistry that we send. I would probably send a CK in this patient because she's been lying on the floor on a blood gas venous or arterial, depending on the circumstance on by Think this lady needs and arterial gas. What about a troponin? When might you send a report in? So if the patients had a concerning collapse, cardiac signing chest pin, uh, concerning ischemic changes, uh, or evidence of a sternal fracture on imaging, you might send a report. And if you're concerned about cardiac confusion, remember what we said earlier on the risk of type two? Um, I if these patients were shocked, they're not going to refuse the coronary arteries. If especially if they have concomitant cardiac disease. No, in a cool get to your PCG on this is, uh this is our patient CCG. So, what we think about this? Anyone able to tell me what the CT shows? Why I might be significant? Yeah. Okay, so it's been a partial right bundle branch spoke. That's one part of it, right? Bundle branch block on its own isn't concerning what goes along with it. So the PR interval looks pretty prolonged more than 200 million seconds. Um, there's some axis deviation is what else would probably left anterior hemiblock. This is try for secure block. What's the risk with try for secure block on. Why? Might be significant. Yeah, perfect. So just a few. Just a Z. You look at the CT, you hear the monitor go and you look up to see, uh, just a couple of screens of this. Um, So you're having a couple of rooms off complete heart block there without quickly goes back. Teo, the Sinus Sinus rhythm. I'm will not worry any further about it for the time being. Okay, so, imaging, Lots of different modalities. X ray of some benefit. Let me x rays later, Possibly a portable chest X ray. If there's gonna be a significant delay to CT or to check your tubes, um, strains and lines and things. Um, point of carol just signs is a limited benefit. Should not delay transfer to CT. And it's either positive and she was free fluid in the abdomen or it's unhelpful. Um, you certainly wouldn't say it's a negative. It is useful in chest on, identifying long sliding or possibly athlete in the girl company. Well, about the CT is the gold standard. Um, it allows us to demonstrate expected on Dakhil injuries. There's no convincing evidence for significant effects of Phoenix contrast on renal function on, in this case, the benefits significantly, I waste the risk off renal impairment from contrast, induced the prophecy. Just a little caveat. We talked about the significance of neck injuries. Just remember to consider a CT angio. If you have any suspicion of vertebral artery dissection in neck injury. It's possibly something that we overlook a little bit. MRI, maybe required later. And your spinal or some S S K conditions, but certainly no, it's part of the primary survey. What? What? Your analysis, Johnny has You're well versed in the in the use of your analysis. Probably not helpful. These patients are unlikely to be pregnant. Um, it shouldn't be performed in the over 70 five's for grade infection. We're already getting a contrast CT. So although you might see microscopic hematuria in urinary tract injury, we would hope to pick up a significant entry on CT anyway, So get doors to this counter on, uh, these are the images that come back. So she's had a CT scan. What is this one show? Just the right sided subdural hematoma, Possibly a bit of midline shift. Bit of a basement of the ventricles. What do we need to do? Here's a chest ct. So what does that show? Yeah, So there's a right sided, uh, pneumothorax. There's also you can see some some rec center of fractures as well. Excellent. Oh, good point standing. Think it on under the abdomen. Can anyone see the abnormality and not Remember, we had some right sided rib fractures. Yeah. So liver laceration, big expanding hematoma. Probably some active hemorrhage. She can see contrast. Plus, there's well, so these are some pretty serious injuries, you know? I will. What we do, we're gonna re assess. I'm treated. You meet. So airway remains patent. Um, saturations on oxygen were 95 96%. Is there anything else we would like to do and be okay? Yeah, I think it would be reasonable to put a drain in. It's a small enough. You miss your axle. Depending on the scenario, you could probably make an argument for, uh, conservative watchful waiting of that for the time being on but your brain in later and in on what other priorities you have. You should start treating okay on high flow oxygen. But that's not to say that she will remain that way. Uh, circulation. We need to turn off the top. We talked about t X. A crash, too. Uh suggests that there's benefit to giving T X ray within three yards off injury where you're concerned with hemorrhage. Cross three. Um, we should be thinking about giving T X ray within three hours of a significant head injury. GCS of less than 13. Talk to him a collagen. But ultimate is gonna be off defects on blood products. If she's significantly shocked, we might consider the massive transfusion protocol. Yeah, you really need to. Laparotomy is well for that for that liver, but we need to consider carefully highway proceeds d with a subdural, um, currently new clinical evidence of worrying increased intracranial pressure. Um, but we need to think about preventing secondary brain injury in anticipation off surgical management of that. So it's a little quick. Better bite prevent exactly brain injury. There are a few measures which we can do in the first instance, such I was raising the head of the bed up 30 degrees, voiding having a tight neck color, which impedes venous drainage back from the heads. Even if you're not ready to quit to clear the neck as long as the patient keep still, you can leave even the front part of Ah um, a softer color over the max just to remind people to be careful and sure adequate analgesia avoid hypoxemia avoid hypovolemia profusion, unavoidable or hyper cap mia on high buan hyperglycemia, which can cause osmotic shifts. And I don't really want to go too much into cerebral perfusion pressures and mom locally doctrine on that kind of thing. But with a clinically significant brain injury that you may opt Teo target a slightly higher systolic BP or higher mop than you would with the permissive hypertension in the well, I in a normal dramatis, just insure the brain is still perfused on doors. A. GCS was 12 last time. We checked 13 just before that. So doesn't currently require intubation I ever in your in your back patient with neuroprotective ventilation, maybe required if her physiologist periods much further. So in some rate for an eye for our patient. Head up 30 degrees cooler, loosens or off. Avoid hypertension on, then watch her GCS and her respiratory function. If you were to see this, you might be a bit more concerned. Unilaterally blowing people fixed and dilated in a head injury, particularly with reducing GCS uh, is suggestive, increased intracranial pressure, um, with concerned about him it coming, causing compression of the third nurse. You might also see a unilateral contralateral weakness, maybe a guess balls here. Tosis compensation occurs when the increased pressure from Cardura, Dema or lesion could no longer be compensated by expulsion. CSF bloods that from the skull, You can take a bit longer, as we said in older people, because they have a bit more space because of the cerebral atrophy. So what are we going to treat? Not with surfing? Yeah. Yeah, that healing tauruses up to surf in today. But eso anybody? What's the celebrity of seawater? What's the concentration of seawater? Roughly. So, um, see, water is about 3.5% sold concentration, treatment of raised into pretty of pressure. In this context, we treat with Yep, thanks. Going treat with hypertonics saline. So we have 2.7% saline here or 3% saline, and we have three mils per kilogram of 3% selling over with 10 minutes. Uh, it is also possible to use my little you give 0.252 point 5 g per kilo. And that's of ideal body weight. And they're different concentrations. We have the 20% concentration here. We're just caution with use of mannitol that it can cause a significant diaries is which will likely require ongoing fluid resuscitation following that when they start to diaries. So where are we going? Where does Doris need to go? What are our options? Were gonna admit her locally under the surgeons. Yeah. So, um, we have ah, with the major trauma network. We have a cold sand pathway which looks like this. And there are several markers to do with anatomical on the mechanism of different things. Teo dictate what is major trauma. But I think in fairness, our patient probably meet stop criteria. So vision is any d She has a suspected injuries. Very for a great and 15. Um, we arranged hyper acute transfer to the major. Trauma was cold. So I'm sure many of you have heard me runs. What's the CR on? The fact that we don't useful till we don't need to use it for every single patient. I think when you have the trauma team present in this circumstance, it's beneficial to allocate someone to go into a deep dive into the patients and medical notes of medical history on the CR. Unclear about with collateral history, social history, information about functional baseline important decisions need to be remitted regarding, um, the high risk surgery and anesthesia elderly patients whose frail transferred to the major trouble center. So we just let it go. Just you need any treatment on route? Yes. Come. You could indeed. Um, if you have a spends on your clothes on your suspicion of injury, you know, Doris have a lot of crepitus on, um, bruising right down the side of her flank. It depends on high accessible. Your CT is, doesn't it? Um, What the timeframe is you're gonna be if it's gonna be, um, half an article. Your ambulance. You may benefit from getting the CT. In the meantime, um, so we're gonna need any treatment on the road, or, uh, do we just stick it in the box and center on our way? Um, does anyone need to go with her? Should you go it all? She's gonna need blood products. She probably needs to someone to accompany her. If you're worried about her airway or coma, then she's gonna need someone capable off, uh, maintaining her airway or providing anesthetic, um, interventions on route. So because quite right, probably an anesthetic transfer. Uh, but the long and short of it is don't just send anyone The surgical have to, uh, isn't going to be any help in the back of the ambulance. They're not able to provide any enhanced care that the paramedics come to provide. So if you're sending someone, it has to be the right person. What of Doris to terrier? It's significantly drops of BP, despite Lord resuscitation, uh, continues to drop a GCS um, you don't get to restart. Actually, her medical history is a bit more significant than, uh, Then you initially thought, Well, anesthetics are more than kid was putting that et tube in before the goes on the gum. So mortality is, ah, high among elderly patients sustaining trauma. Would you recognize it? Doris is dying. And if she is, is it appropriate or fair? Too cold? Sanders, Belfast If you might die on roots or die when she gets there or die when she goes to theatre during induction, it's going to do it. We'll get it this afternoon about dying martyrs on ceilings of treatment and palliation and e. D. We've kind of talked about it already, so I'm not saying this is the case with our patient, but it's just it's worth having that in the back your head's. It's worth thinking about that consideration. Um, not everything needs treated or should be treated. Know every injury or illnesses survivable. Let's fast forward. Remarkably, Doris can survived her life saving surgery on her head's on her test under abdomen, or maybe has been treated for Sinus. Last. Severe injuries perhaps, but anyway, she's recuperating. She's been repopulated to rehab boards. What happens now? I firstly, after surgery, she needs a formal secondary service survey, which is your, uh, top 22 assessments. 80 less talk about It's the head and skull marks, fax exam C spine, chest, abdomen, pelvis perineum orifice is urological exam msk A, including all limbs and joints on any further diagnostic tests, including X rays. MRI's further blood tests echo all these kinds of things. We need to ensure the treatment for the underlying cause of the fall is identified. Um, as we know, there's a distinct possibility that our patient suffered a syncope or possibly was in complete heart book, so need to address those kind of things, too. Then, in his book about two on getting Doris back on her feet sooner she can leave hospital the better. Critical illness, weakness, effects, even young fit trauma victims we could I see you on. So the deconditioning will be significant after such a heavy, heavy physiological assault on this elderly lady. The expertise of are excellent colleagues and failed and rehabilitation is crucial to getting Doris up about it, including the whole and et communicate with Doris and her family. Or, next week, Kim exploring her goals and wishes. Is it suitable to set a ceiling of treatment or to discuss the protection of the DNA CPR? Um, ensure that she has her hearing AIDS glasses, dentures, walking It's anything else. She uses it home to make her life, um, easy to live. Help keep her or intense recognizing. Treat delirium early. Remember that pre prolonged hospital stay increases mortality in these patients, so that's it. In summary, silver trauma is under recognized. The most common mechanism is a full from standing height. The most common injuries are heading thoracic. The most common cause of death is a traumatic brain injury. It's important to consider comorbid status, medications, social history and functional baseline and frailty. We've talked about about the pathophysiology of several drama talked about the primary survey assessment, treatment, disposition and transfer realistic expectations. Schools of care on the importance off rehabilitation. So that's me. I'll take any questions. I've collected a few useful links to some really good resources on the link three that's attached backyard code. So make sure you don't explore those, thank you. And thanks so much dot That's great. And if any questions come up on the chat box and we can put down these on the hot seat and make them nice and tough on the hard question is for gone. There's one from January, he says, Just wondering about your costume Really low grow. So you know what? What benefits does logroll logrolling do? You're gonna see everything on the CT scan, and you need to be really cautious in handling these patients, particularly if they've got, say, displaced rib fractures, irritating a liver laceration if they've got any unstable spinal fractures, Um, the most you should do is have that kind of minimal tilt 10 15 degrees to get your script and a right to get any clothing in her in, right on down. You know, have a quick look at the back when you're doing that. But we certainly don't advocate the classic 90 degree log rule that they talk about in a TLS. Um, yeah, that's a really good question. Call. Um, I'm a little, um, defect any of my colleagues as well, but I think there are probably a lot of patients in whom simple. Typically, my fractures are simple pubic hair. My fractures on the fact that they've got a slight dust of the S I joint accompanying that is maybe academic I ever It's recognizing the fact that they're not all simple, benign injuries on the patient who remains off their feet very sore or whose human dynamics or not, what you would expect to give them their physiology and, you know, calmer. But status on the medications their own might lower your threshold for doing CT. I would also argue that we need Teo kind of realign are, um, sort of expectations of which patients need CT in general and silver tomah. We probably understand under recognized the patients who have sustained major trauma anyway, so probably should be pounds counting a lot more of these at these folks. Uh, regardless, Okay, So we're way and glad let down off the headache because I think we did move on with our, uh, with our schedule. So make so much done. Uh, we had talked last for pens. There was presentation. So I think he almost even if you have any questions for down, you can corner room attacks the next time you see him. So let me just