2024.2 Day 2 VIVA 16

Resuscitation, Trauma and Crisis Management

You have been called to the emergency department to assist with a 45-year-old female who has been stabbed near her clavicle with broken glass. She drank several alcoholic beverages before the incident and has a Glasgow Coma Scale (GCS) score of 14.

She has significant subcutaneous emphysema, dyspnoea, and is coughing up blood. The ambulance is expected to arrive at Scenarioville Hospital in 12 minutes.

Your expertise in airway management and resuscitation is needed.

How will you brief your assistant to prepare for the patient’s arrival and your anticipated plan?

Trauma Reception Planning:

• Declare trauma call. Assign team roles: Airway lead, IV access/monitoring, surgical support.

• Ensure trauma bay readiness with resus equipment, suction, oxygen, and PPE.

Airway Preparation:

• High likelihood of compromised airway: prepare RSI and surgical airway setup.

• Video laryngoscope, bougie, dual suction, and cricothyroidotomy tray ready.

Breathing Support:

• Subcutaneous emphysema + hemoptysis = likely pneumothorax and airway injury.

• Needle decompression kit and chest drain setup prepped bilaterally.

Circulatory Access and Resuscitation:

• 2x14G IVs or IO access. Preload blood warmer and MTP protocol.

• Activate O-negative PRBCs and FFP if available.

Monitoring & Imaging:

• Full monitoring including EtCO2 post-intubation.

• POCUS on arrival for lung sliding and cardiac views.

Why might/would you elect to intubate with GCS 14?

• GCS 14 with signs of evolving airway compromise (hemoptysis, subcutaneous emphysema) indicates significant risk of sudden deterioration.

• Hemoptysis suggests bleeding into airway which can rapidly obstruct the view and airway.

• Early controlled intubation preferable over rushed crash airway. Also accounts for possible intoxication masking worsening mental state.

You hear worsening stridor en route. What changes?

• Stridor implies upper airway obstruction → anticipate difficult or failed intubation.

• Alert ENT for standby tracheostomy or surgical airway.

• Prepare for awake intubation if patient maintains GCS or controlled surgical front-of-neck access if obstruction worsens.

• Ensure ENT/vascular instruments, rigid bronchoscopy available if foreign body suspected.

She has a visible sucking chest wound. Management?

• Immediate 3-sided occlusive dressing to create a seal and prevent air entrainment.

• Monitor for clinical signs of developing tension pneumothorax.

• Perform finger thoracostomy with subsequent ICC on affected side.

• Avoid positive pressure ventilation until chest decompression is established.

Scenarioville has no platelets. What is your transfusion plan?

• Aim for balanced resuscitation using available components.

• Administer 4 units O-negative PRBCs with 4 units FFP in a 1:1 ratio.

• TXA 1g IV stat, consider repeat at 3-hour mark.

• Use cryoprecipitate to support fibrinogen levels, aiming >1.5 g/L.

• Regular monitoring of coagulation (if lab support available) and clinical response.

Your junior hasn't used a videolaryngoscope before. What do you say?

Provide clear, simple instructions:

• Insert blade midline and avoid sweeping the tongue.

• Advance slowly until glottis is visualised centrally.

• Use a 30° angled stylet and advance the tube under direct screen vision.

• Emphasise teamwork – you will talk them through each step, and suction may be needed continuously due to hemoptysis.

The patient arrives hypoxic (SpO2 88% on NRB). Walk me through your airway management plan.

Airway Strategy:

• Preoxygenate with NIV (PEEP 10, FiO2 1.0) while preparing equipment.

• RSI using ketamine (1.5 mg/kg) for haemodynamic stability and rocuronium (1.2 mg/kg) for optimal paralysis.

• Dual suction setup; consider intubating in lateral position if bleeding profuse.

• ENT and surgical airway equipment at bedside.

Anticipated Difficulties:

• Blood obscuring glottis – manage with dual suction and prompt laryngoscopy.

• Subcutaneous emphysema can distort anatomy – use videolaryngoscopy.

• Tracheobronchial injury risk – ventilate cautiously with lower tidal volumes.

Post-intubation, ETCO2 is 15 mmHg, SpO2 92%. Next step?

• Low ETCO2 suggests poor ventilation or dead space – consider tension pneumothorax.

• Immediately perform bilateral needle decompression if tension suspected, followed by ICC.

• Reconfirm tube position via waveform capnography and clinical signs.

• POCUS lungs for lung sliding; absence supports pneumothorax diagnosis.

Right lung doesn’t inflate after ICC. Thoughts?

• Suspect right mainstem bronchus injury or massive haemothorax.

• Reassess ETT placement with bronchoscopy to exclude mainstem intubation or trauma.

• If airway injury confirmed, escalate to cardiothoracic surgery for definitive management.

• Prepare for thoracotomy if unstable.

She now has subcutaneous emphysema down to abdomen. Implications?

• Extensive emphysema suggests major airway breach with air tracking.

• Risk of tension pneumomediastinum or tamponade.

• Avoid nitrous oxide due to expansion of air spaces.

• Maintain low tidal volume ventilation. If stable, proceed to CT chest/neck for surgical planning.

SpO2 drops to 75% during attempt 2. Action?

• Abort further attempts immediately.

• Insert supraglottic airway (e.g., LMA) to oxygenate.

• If no improvement within 60–90 seconds, proceed to front-of-neck access.

• Maintain situational awareness – limit total intubation attempts to two per difficult airway algorithm.

Imaging shows a glass shard in zone 1 of the neck. Plan?

• Zone 1 injuries carry risk of vascular and airway trauma.

• Avoid neck manipulation to prevent vessel disruption.

• Opt for awake fibreoptic intubation if airway control required and patient stable.

• Coordinate with ENT and vascular surgeons; consider pre-op angio-embolisation.

Post-intubation, she becomes hypotensive. Outline your management.

• Differential Diagnosis:

  • Tension pneumothorax

  • Cardiac tamponade

  • Haemorrhagic shock

  • Drug-induced vasodilation

• Immediate Actions:

  • POCUS: assess cardiac activity, IVC, lung sliding.

  • Decompress chest if signs of tension pneumothorax.

  • Transfuse O-negative PRBCs promptly.

  • Maintain permissive hypotension unless TBI suspected.

  • VBG: assess lactate, Hb, acid-base.

POCUS confirms pericardial fluid. Now what?

• Suspect tamponade if hypotension persists with pericardial fluid.

• Perform pericardiocentesis via subxiphoid or apical approach under US guidance.

• If patient decompensates, prepare for emergency resuscitative thoracotomy.

• Avoid volume overload; maintain adequate preload only.

Hb is 68. What blood products and targets?

• Continue 1:1 resuscitation with PRBCs and FFP.

• Add cryoprecipitate if fibrinogen <1.5 g/L.

• Give TXA 1g IV stat and repeat at 3 hours.

• Target SBP 80–90 mmHg for trauma without TBI; higher if TBI present.

• Monitor response clinically and via labs.

Retrieval team ETA is 2 hours. What monitoring do you establish?

• Insert arterial line for beat-to-beat BP monitoring.

• Central line if vasopressor support or CVP guidance needed.

• Serial VBGs for lactate and base deficit trend.

• Monitor urine output hourly (UO >0.5 mL/kg/hr).

• Continuous ECG, pulse oximetry, EtCO2, and temperature monitoring.

New onset AF. What now?

• Assess for underlying triggers: hypoxia, pain, acidosis, electrolyte imbalance.

• Correct electrolytes (K+ >4.0, Mg2+ >1.0).

• If haemodynamically unstable, initiate amiodarone 300 mg over 20–30 mins.

• Avoid beta blockers due to risk of hypotension.

• Escalate if rhythm persists or instability continues.

How do you handover to the retrieval team?

• Use ISBAR: include mechanism of injury, suspected injuries, interventions, and vital trends.

• List administered drugs, timing of interventions, and ongoing concerns.

• Highlight airway challenges, risk of deterioration, and blood product availability.

• Provide printed and verbal summary; confirm team readiness and transport logistics.