material used for final exam preparation *at own risk

1. Batch c2
Case scenario 2 22042021
A 35-year-old man was found unconscious on the roadside. He was brought in by
ambulance.
Vitals:
HR 125 per min, tachycardia
BP 85/55, hypotensive
RR 25, respiratory distress
O2 90% under HFM, not maintain optimum Spo2 at room air
1. Perform airway assessment
Identification Intervention
No gag reflex ● Assess patient’s level of consciousness
● Do cervical spine immobilization
● Open airway with jaw thrust and assess airway
patency
● Clear the airway from blood or any secretion by
doing suction, if there is foreign body then
remove it with McGill forceps or fingers
● Insert OPA
● Give humidified high flow O2 - 10 to 15L/min,
non rebreather mask
Definite management: May require intubation since
there is absence of gag reflex

2. Batch c2
2. Perform breathing assessment
Identification Intervention
Look: tachypnea, use of accessory
muscle, asymmetrical in chest
movement, stridor
Feel : percussion, crepitance
Listen: absent or decreased breath
sounds, additional sounds.
Tachypneic
Reduced chest movement on left side
Tracheal shifted to right
Dullness over left chest
Absent breath sound over left chest
*suggestive left massive hemothorax
- Pulse oximetry to monitor
spo2.
- Continue high flow oxygen.
- Chest tube insertion.
- Do a chest x ray.
- Thoracotomy
- Consider blood
transfusion (replace)
- Too much blood, clamp
the tube
After your intervention, vital signs have improved, and you move on to circulation
assessment.

3. Batch c2
3. Perform circulatory assessment & disability assessment.
Circulatory assessment:
- Assess level of consciousness by using AVPU Scale
- “Open your eyes, squeeze my hand” or squeeze both shoulders firmly.
If fail to respond, pt is unresponsive
- Assess skin perfusion: pink or pale
- Assess pulse:
- femoral or carotid artery bilaterally for quality, rate, and regularity
- Thready pulse is a sign of hypovolemia
- Assess BP, heart sounds
- Identify source of hemorrhage: internal or external
Intervention
- Secure 2 large iv bore cannula.
- Draw blood for blood grouping, cross matching and blood investigations.
- Administer iv fluids therapy and o negative blood transfusion.
- Once cross matching report done prepare for appropriate blood group
transfusion
- Identify active external bleeding: controlled by direct manual pressure.
Disability assessment:
● Examine the pupils noting the size and shape
● Check pupillary response
● Assess for GCS score
○ Eye opening
○ Verbal response
○ Motor response
● Check for lateralizing sign
○ Assess movement of upper extremities
■ Determine upper extremity strength bilaterally, and compare
side to side.
○ Assess for movement of the lower extremities.
■ Determine lower extremity strength bilaterally, and compare side
to side.

4. Batch c2
4. Exposure
. You do the log roll and find the following wound:
At this stage, Patient condition deteriorates and is hypotensive. You repeat the
ABCDE assessment of the primary trauma survey.
On circulation assessment:
Identification Intervention
1. Neck veins are distended
2. Heart sounds are muffled
3. BP80/35
- Finding consistent with Beck triad
- Probably pericardial tamponade
- Perform FAST scan (*subxiphoid
view/apical 4 chamber view)
- Confirm by ECHO
1) Emergency thoracotomy or
sternotomy or open pericardiectomy
(cardiothoracic surgeon)
2) Administration of intravenous fluid

5. Batch c2
3) If surgical intervention is not
possible, emergent
pericardiocentesis followed by
pericardiotomy can be
therapeutic. (Temporary)
● Emergent needle
pericardiocentesis using
long over-the-needle
catheter (18-22G)
● Seldinger technique
insertion of a flexible
catheter at xiphisternum
towards left shoulder 45°
under US guided;
aspiration ~60cc can
stabilise BP
https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.aliem.com%2Fdifferen
tiating-pericardial-effusion-tamponade-
ultrasound%2F&psig=AOvVaw0vXSoyo7dfbdN0BxkfG3Zt&ust=1619151801322000
&source=images&cd=vfe&ved=0CAIQjRxqFwoTCOiH8aWBkfACFQAAAAAdAAAAA
BAD
https://www.youtube.com/watch?v=jQxX4ONGi58
Pericardial effusion
https://www.youtube.com/watch?v=scBvGaG5v0I
Pericardiocentesis

6. Batch c2
Case scenario 3 22042021
A 30-year-old man was shot at his right chest by a man using a revolver after
quarrelling over a lady. He was riding a motorbike and tried to hit the assailant but
instead he was shot and fell from the motorbike.
On arrival at ED where you are stationed as a house officer, he is fully conscious,
alert, orientated.
He complained of severe pain over the right chest and difficulty in breathing.
1. Perform airway assessment of primary trauma survey.
Identification Intervention
- Fully conscious
- Alert
- Oriented
● Assess patient’s level of consciousness
● Do cervical spine immobilization
● Open airway with jaw thrust and assess
airway patency
● Clear the airway from blood or any
secretion by doing suction, if there is
foreign body then remove it with McGill
forceps or fingers
● Insert OPA
● Give humidified high flow O2 - 10 to
15L/min, non rebreather mask (based on
spo2)

7. Batch c2
2. Perform breathing assessment of primary trauma survey.
Identification Intervention
Look: tachypnea, use of accessory
muscle, asymmetrical in chest
movement, stridor, contusion, wound
Feel : percussion, crepitance
Listen: absent or decreased breath
sounds, additional sounds.
Open chest wound over right chest with
hissing sound air going in and out
*suggestive open pneumothorax
Continue administering high flow
oxygen.
Cover the wound with 3 side dressing
- Tape it securely on only three
sides to provide a flutter-valve
effect
- Place a chest tube remote from
the wound as soon as possible
- Subsequent definitive surgical
closure of the wound is
frequently required
Chest x ray

8. Batch c2
3. Perform circulating assessment of primary trauma survey.
Identification Intervention
● Assess level of consciousness
by using AVPU Scale
○ “Open your eyes,
squeeze my hand” or
squeeze both shoulders
firmly. If fail to respond, pt
is unresponsive
● Assess skin perfusion: pink or
pale
● Assess pulse:
○ femoral or carotid artery
bilaterally for quality, rate,
and regularity
○ Thready pulse is a sign of
hypovolemia
● Assess BP, heart sounds
● Identify source of hemorrhage:
internal or external
Tenderness over pelvic bone
Patient lethargic
Cold periphery
CRT 5 sec : prolonged
HR 140: tachycardia
BP 60/30: hypotension
*4th stage of shock
Secure 2 large bore iv cannula.
Draw blood for blood grouping,
baseline investigations and cross
matching.
Administer iv fluids and blood
transfusion.
Pelvic binder/wrap in situ
Appropriate referral
X ray of cervical vertebra, chest,
abdomen, pelvic and long bone)
Ct trauma series
FAST scan
- Hepatorenal pouch
- Splenorenal pouch
- Pelvic cul-de sac (retrovesical
pouch)
- Pericardial view

9. Batch c2
4. Perform disability assessment of primary trauma survey.
Identification Intervention
● Examine the pupils noting the
size and shape
● Check pupillary response
● Assess for GCS score
○ Eye opening
○ Verbal response
○ Motor response
● Check for lateralizing sign
○ Assess movement of
upper extremities
■ Determine upper
extremity strength
bilaterally, and
compare side to
side.
○ Assess for movement of
the lower extremities.
■ Determine lower
extremity strength
bilaterally, and
compare side to
side.
GCS 8/15
GCS 8 and below: prepare for
intubation and ventilate
CT scan of brain

10. Batch c2
5. Exposure
Identification Intervention
Patient is shivering
High riding prostate
● Maintain temperature by
providing a blanket and warmer
to prevent hypothermia that
might lead to coagulopathy.
● Warm saline infusion, (blood
product must be warm)
● Suggestive of posterior urethral
injury - avoid catheterisation,
prefer suprapubic cystostomy
○ Early referral to primary
team (urosurgery)
6. Perform the primary adjunct.
- ABG analysis
- ECG monitoring
- Trauma series
- Chest + pelvic x ray.+ lateral cervical spine
- FAST scan.
- CT brain and abdomen.