2023.1 Day 1 VIVA 1

CANDIDATE INSTRUCTIONS

It is a Sunday afternoon in Scenarioville and you are called to ED. The patient is a 30-yearold male who has rolled his quad bike. He has a fractured femur and a head laceration on initial assessment. His heart rate is 120 bpm and Blood Pressure is 80/40 mm Hg.

What are the potential causes of hypotension? 📃(Notes)

Answer as per all potentially multi-factorial shock related questions:

• Haemorrhagic shock (most likely) – fractured femur, possible intra-abdominal/thoracic/pelvic bleeding

• Neurogenic shock – spinal cord injury

• Obstructive shock – tension pneumothorax, cardiac tamponade

• Cardiogenic shock – myocardial contusion

• Distributive shock – septic shock (unlikely acute

What is your initial management for this patient?

Management begins before arrival of the patient

• Activate a Trauma Call – inform the trauma team

• Assign roles (team leader, airway, circulation, etc.)

• Prepare resuscitation bay: airway equipment, IV access, blood products, imaging as available

• Call for senior help early (anaesthetics, surgery, ICU, radiology)

• Alert retrieval services early if more information available

• Consider videoconference "eye in the sky" assistance.

Outline your Primary Survey approach to this patient:

Consider this with the ATLS approach (CABC)

• C - Catestrophic haemmorhage and C-spine - Address major observable bleeding

• A – Airway with C-spine protection: Assess patency, maintain inline immobilization

• B – Breathing: Look for chest injuries (tension pneumothorax, haemothorax)

• C – Circulation: Identify & control external bleeding, FAST scan for internal bleeding, IV access

• D – Disability: GCS, pupils, neuro exam

• E – Exposure & Environment: Fully expose, assess for hidden injuries, prevent hypothermia

Q: How would you manage the hypotension in this patient? 📃(Notes)

• Secure IV access (large bore x 2)

• Fluid resuscitation: Start with warmed blood (massive transfusion if needed)

• Pelvic binder if primary team have not as pelvic fracture suspected

• Potential urgent surgical/radiological intervention if active bleeding

• Maintain permissive hypotension (SBP ~90 mmHg) in trauma unless TBI is suspected

The patient’s GCS drops from 12 to 6. What are your immediate concerns?

• Airway compromise – reduced GCS → loss of airway protection

• Rising ICP / brain herniation – worsening TBI

• Hypoxia or hypotension – exacerbating secondary brain injury

• Expanding intracranial haemorrhage – subdural, extradural, contusion

What are your indications for intubation in this patient? 📃(Notes)

• GCS ≤ 8 – loss of airway reflexes

• Hypoxia or hypercapnia – unable to maintain oxygenation/ventilation

• Worsening neurological status – signs of raised ICP (unequal pupils, decerebrate posturing)

• Haemodynamic instability requiring aggressive resuscitation

Q: Describe your intubation strategy in this patient with TBI.

• MAIDE First

  • Monitoring

  • Assistant

  • IV

  • Drugs

  • Equipment

• Team preparation – Airway anaesthetic team present, roles allocated, include MILS person/plan, preoxygenation, difficult airway plan

• Induction drugs:

  • Ketamine (if normotensive/hypotensive)

  • Rocuronium/Suxamethonium for rapid sequence induction

• Approach

  • Early intubation for GCS ≤8 or deteriorating GCS

  • RSI with full preparation and skilled operator

  • Maintain MAP during induction (ready vasopressors)

  • Avoid succinylcholine if >48hrs post-injury (↑K+ risk)

  • Opioid pretreatment to blunt response to laryngoscopy

  • Ensure ETCO2 35-40mmHg immediately post-intubation

  • Avoid nasal intubation with base of skull fractures

• Post-intubation Neuorprotecitve care:

  • Head up 30 degrees,

  • loose ties, head midline,

  • Maintain normoxia (PaO₂ > 100 mmHg),

  • Normocapnia (PaCO₂ 35-40 mmHg),

  • Normotension (SBP > 110 mmHg),

  • normothermia

  • Glucose management

Q: What strategies would you use to prevent secondary brain injury? 📃(Notes)

• Optimize oxygenation & ventilation (SpO₂ > 94%, PaCO₂ 35-40 mmHg)

• Maintain SBP > 110 mmHg (fluids, vasopressors if needed)

• Elevate head 30 degrees (if no contraindication)

• Control seizures (prophylactic levetiracetam if indicated)

• Early neurosurgical involvement

What are the potential issues with intubation of a patient with a C-Spine collar? 📃 (Notes)

Intubation should be altered to take place with MILS. Issues arising from this include:

• Worsens Laryngoscopy grade by 1 level

• Reduces mouth opening by > 1cm.

• 20% reduction in first pass success.

• 30% increased intubation time

Technical considerations for laryngoscopy under MILS:

• Use Video laryngoscopes with hyperangulated blades

• Bougie use more difficult due to restricted manipulation space

Impact on airway strategy:

• Need for extended pre-oxygenation due to longer intubation times

• Rescue techniques more challenging

• Front-of-neck access may be complicated by assistant's hands

• Consider releasing MILS in can't intubate, can't oxygenate scenario

• Explicit plan for MILS release if emergency airway needed

What are your key considerations when organising retrieval to a tertiary trauma centre? 📃 (Notes)

• Early activation of retrieval services (aeromedical or road transfer)

• Triage to highest-level trauma centre (neurosurgical & ortho capabilities)

• Ensure patient is stable for transport (airway secured, haemodynamics optimized, ongoing sedation & analgesia)

• Communication with retrieval team (handover, anticipated issues en route, receiving team accepted patient)

While waiting for transfer, how would you manage this patient? 📃(Notes)

• Continued haemodynamic resuscitation – blood products, vasopressors if needed

• Ventilation targets – SpO₂ > 94%, PaCO₂ 35-40 mmHg

• ICP control measures – head elevation, avoid hyperthermia, sedation with fentanyl/midazolam, losse ties, paralysis.

• Monitor for deterioration – worsening GCS, hypotension, unequal pupils → escalate care

• Ensure ongoing analgesia and sedation