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The trauma clinical scenario is similar to the main clinical structure, with the addition of some key additional details.
Top tips:
Don’t jump straight into your ABCDE assessment
Sign post your clinical concerns and escalate to seniors early and impress the interviewer!
Easy marks are awarded for prioritisation - e.g., don't spend ages on exposure if you know a focused exam of the limb is clear in an open fracture
When assessing the patient, use the Adult Trauma Life Support (ATLS) structure that is outlined below.
For this example: A patient has arrived to A&E with an open fracture following a RTA (road traffic accident).
Set the scene
This is a critically unwell patient following major trauma. I would ensure they are managed in the A&E resuscitation bay and that a Trauma call has been put out to ensure the appropriate team is in attendance (know the members of a trauma call)
I would commence the primary survey following ATLS principles and would assess and resuscitate the patient in an A to E manner.
ATLS specific
C - spine - I would triple immobilise the cervical spine, using head blocks and tape
If the patient is drowsy/non-responsive (GCS <8) I would consider early escalation to anaesthetics for a definitive airway due to risk of compromise. If I observe any obvious signs of haemorrhage or haemodynamic instability I would escalate to the MHP (Major Haemorrhage protocol) early.
I would want to assess this patient in systematic manner with ATLS principles as the open fracture could be a distracting injury.
Primary Survey
Airway
I would ensure airway patency and use suction or adjuncts if necessary. If the patient is speaking, the airway is patent and I would move on to assess breathing.
Breathing
Look: I would inspect for obvious signs of chest wall trauma such as bruising, open wounds, flail segments or unequal chest expansion.
Feel: I would then palpate and percuss and auscultate the chest for symmetrical expansion, reduced air entry or added breathing sounds. I would also feel the trachea's position. Primarily ruling out a tension or haemothorax.
Measure: I would check O2 saturations and respiratory rate and treat accordingly, with a 15L NRBM and consider and ABG if desaturating for indications of respiratory and metabolic compromise.
I would reassess, treat any pathology and then move on to assess the patient's haemodynamic stability.
Circulation
I’d feel their peripheries, pulse, get a BP and CRT reading, inspect their JVP, mucous membranes for hydration status.
I’d palpate and auscultate the heart and request an ECG reading.
At this point I’d gain large bore vascular access in each ACF and ask for a panel of bloods - FBC, U&E, CRP, LFTs, Coag and clotting screen, TEG (checks coagulation in the acute setting) , CXM and G&S.
I'd consider the use of a fast scan to rule out any free fluid in the abdomen and also consider initiating the major haemorrhage protocol if worried about a massive bleed with the aim to give O-neg blood asap.
I'd also consider giving 1g of tranexamic acid as per the CRASH 2 trial which ahs shown to reduce mortaility in major trauma patients
Immediate management:
I'd ensure that I follow management as outlined by the open fracture BOAST guidelines and escalate to the Orthopaedic SpR as soon as possible if not present already at the trauma call.
If hypotensive I would start a 500ml bag of crystalloid solution STAT (250ml if known cardiac failure),
take blood cultures
start broad spectrum abx as per local hospital guidelines,
Give Tetanus
Remove gross contaminants
Dress the wound with soaked saline gauze
and take medical photography
insert a urinary catheter to monitor input and output and ensure the Sepsis 6 is complete.
Disability
I'd reassess A-C and if responsive then move on to assess their neurology.
I'd check their GCS, the size and reaction of their pupils to light
and measure their blood glucose and temperature
Exposure
I’d then expose the patient maintaining dignity and normothermia and do a top to toe examination followed by a focused examination (Lower limb in this case)
E.g., I would inspect the limb in a look feel and move manner - checking for debris and contamination, open wounds, any active bleeding and keep checking the neurovascular status of the limb.
I'd ensure to check signs of the 6 P's - Pain, pallor, pulse, perishingly cold, paralysis and paraesthesia.
Given an open fracture the patient will need strong analgesia, reduction of the limb and limb traction with a Thomas splint for the short term.
Investigations
Plain flims of the joint above and below with full length views
CT Trauma series if indicated with full body scanogram
If NV compromise, I'd consider an urgent CT angio after discussion with my scenario and expedite joint input with Ortho & Vascular & Plastics
Major Trauma centre?
If in a DGH I would urgently speak to the nearest Major Trauma Centre T&O SpR and action any immediate plan that they might request and arrange trasnfer if accepted
If not for transfer or in a MTC then I would prepare the patient for theatre
Surgery Bundle for a trauma case:
I'd arrange an urgent anaesthetic review
Inform theatre co-ordinator and
speak with ICU/HDU SpR for possible admission post operatively
I'd consent and mark the patient with a consent form 1 (or 4 if they lack capacity) for a debridement + washout +/- proceed.
If the patient is stabilised I would complete a Secondary survey to rule out any other missed injuries and take an AMPLE or collateral History and ensure diligent documentation.
Pathology to revise
Levels of haemodynamic shock
Indications for CT Head
Chest injury
Tension pneumothorax
Haemothorax
Flail chest
Cardiac tamponade - Beck's triad, pulsus paradoxus
Aortic dissection - Stanford classification
Abdominal Trauma
Splenic injury
Urethral/bladder injury
Orthopaedics
Open fracture
Neck of femur
Supracondylar injury
Common ATLS scenarios
Head/spine injury
Chest wall injury
Abdominal viscera injury
Pelvic injury
Open fracture
Paediatric traum e.g., supracondylar fracture
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