Emergency Medicine

Explanation

Answer: Airway with Cervical Spine control> Breathing> Circulation with haemorrhage control> Disability or neurological status> Exposure

In trauma, like resuscitation, an ABC approach is adopted for patient assessment and management (Airway, Breathing, Circulation, Disability, Exposure). In the case of trauma however, the mnemonic is modified to:

• Airway with cervical spine protection
• Breathing
• Circulation with haemorrhage control
• Disability and neurological status
• Exposure/Environment

While in reality, assessment of these areas will run in parallel with a large team, rather than in series with one person, it is important to remember this sequence so as to identify the greatest threats to life first

Explanation

Brayden has what is often referred to as a "distracting injury", the pain and distress from which can easily mask signs and symptoms of more severe or sinister injuries. You cannot confidently assess Brayden’s cervical spine in the presence of such an injury.

The NEXUS group (Hoffman et al., 2000 NEJM 343(2):94-9) validated a simple clinical tool in adults, where if the following five are absent, the likelihood of significant c-spine injury is very small and the neck can be safely assessed:

• DISTRACTING INJURY
• Midline c-spine tenderness
• Decreased conscious level
• Focal neurological deficit
• Intoxication

Furthermore, the Canadian c-spine rules (Stiell et al., 2001 JAMA 286(15):1841-8) mention quadbikes as a specific high-risk mechanism of injury due to their high speed capabilities and lack of rider protection, requiring a very cautious, thorough approach.

Explanation

Paediatric pain is a real priority, however, it must not delay identification of life-threatening injury by slowing assessment. In reality the ambulance crew will have initiated some form of analgaesia, the pre-alerted trauma team can prepare analgaesia in advance, or someone can be spared to prepare this while the team continue.

Appropriate treatment of paediatric pain can actually help identify life-threatening injuries, in addition to reducing anxiety, physiological demands and long term complications.

Explanation

Answer: Constipation

Hypotension:

Morphine can cause a drop in blood pressure, which can be particularly exaggerated in a hypovolaemic trauma patient and damaging to internal organs, especially if already injured. Strategies to limit this are to anticipate it, and titrate the dose given based on patient response, giving the minimum effective dose to achieve analgesia.

Nausea and Vomiting:

Nausea is a common side effect of opiates. Vomiting can be dangerous in the trauma patient who is immobilised on their back, posing an aspiration risk. Strategies to manage this involve concomitant administration of an anti-emetic, vigilance, and securing patients to scoops or spinal boards so they can be swiftly turned laterally and given suction should vomiting occur.

Respiratory depression:

Morphine acts to reduce conscious level and respiratory drive. Careful monitoring is required for early detection and supportive treatment. Reversal of opiate effect would be an unpopular and improper option, as inevitably pain and distress would resume.

Explanation

The long bones, particularly the femur, can bleed extensively. A severe adult femoral fracture can accommodate up to 1-1.5L of blood (20-30% circulating blood volume) in potential spaces created by displacement of bone.

An open fracture can bleed to exanguination. Hence, we rapidly inspect and palpate the long bones when assessing circulation (Blood on the floor, and 4 more), for bruising, swelling, deformity and tenderness. We can also assess circulation to the distal portion of the injured limb, checking pulsation and refil time, in case of local neurovascular injury.

You might also revisit the limb at E) Exposure, looking for external changes and injuries. Depending on circumstances, you may be able to perform imaging of the affected limb in addition to the standard trauma series of c-spine, chest and neck.

Explanation

Answer: Fracture reduction and splintage/immobilization.

These are the only options that will provide pain relief, control of haemorrhage and improvement of circulation. Restoring and maintaining anatomical position will limit bleeding by changing the spherical potential space created by a displaced femoral fracture into a cylindrical one of lesser potential volume (or bringing the ends of the fracture together in an open fracture) while potentially relieving pressure on arteries and veins from displacement and restoring circulation.

Reduction and immobilisation are also possibly the most effective means of pain relief. However, the process of reduction and immobilisation will inevitably be extremely painful and its urgency due to a threat to life or limb must be balanced with achieving suitable comfort.

Direct pressure on an open wound will effectively control bleeding in most cases, however, care must be taken to maintain pressure, and avoid unnecessary removal.

Analgaesia:

In the case of long bone fractures, IV opiates remain the most standard/appropriate IV analgesic. Infiltration of the femoral nerve sheath with local anaesthetic just below the inguinal ligament (femoral nerve block) can achieve excellent pain relief and facilitate reduction of the injury and splintage. Preferably under ultrasound guidance, a mix of long and short acting local anaesthetics can achieve prolonged comfort.

Inhaled nitrous oxide mixed with oxygen can be a very effective analgaesic and procedural sedative, however, caution must be exercised in major trauma as nitrogenous gases can infiltrate and expand gas-filled spaces, worsening a small undiagnosed pneumothorax for example.

Never underestimate the anxiolytic effect of having a reassuring parent present and talking to the child. In their absence, play specialists or child life therapists can have an invaluable role here.

Sedation:

The use of procedural sedation, such as Ketamine, a dissociative anaesthetic, is being used increasingly commonly to facilitate such procedures.

With no life threatening injuries identified, and having achieved a suitable level of comfort, the team perform a femoral nerve block and place Brayden’s leg in a Thomas splint for traction.

Following secondary survey and orthopaedic review, he is transferred to x-ray and then to the ward while further management is planned.