Trauma Resuscitation - Adult

Quick Answer

One-liner: Trauma resuscitation requires immediate, systematic assessment using ATLS ABCDE protocol, damage control resuscitation (permissive hypotension, balanced blood product ratio, early TXA), and rapid definitive hemorrhage control to prevent exsanguination, the leading cause of preventable trauma death.

Trauma resuscitation is the coordinated, time-critical management of severely injured patients to identify and immediately address life-threatening conditions. Approximately 20-30% of trauma patients present with hemorrhagic shock, and exsanguination remains the leading cause of preventable death in the first 24 hours. The core principles include: (1) Primary survey (ABCDE) to identify immediate threats, (2) Damage Control Resuscitation (DCR) with permissive hypotension (SBP 80-90) in non-TBI patients, massive transfusion protocol (1:1:1 ratio), and tranexamic acid within 3 hours, (3) E-FAST ultrasound to identify hemorrhage, (4) Early blood product administration prioritized over crystalloids, (5) Rapid definitive hemorrhage control via surgery or interventional radiology. Time-critical injuries requiring immediate intervention include tension pneumothorax, massive hemothorax, cardiac tamponade, exsanguinating abdominal/pelvic hemorrhage, and uncontrolled external bleeding. ATLS 10th Edition (EMST in Australia) emphasizes limited crystalloids (1L maximum) before transitioning to blood products, balanced resuscitation to prevent trauma-induced coagulopathy, and the "lethal diamond" (acidosis, coagulopathy, hypothermia, hypocalcemia) as the primary resuscitation focus.

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ACEM Exam Focus

Primary Exam Relevance

Anatomy:

• Thoracic vascular anatomy (aortic arch, great vessels, pulmonary vasculature)
• Abdominal vascular anatomy (aorta, IVC, mesenteric vessels, solid organ blood supply)
• Pelvic vascular anatomy (internal iliac branches, presacral venous plexus)
• Airway anatomy relevant to trauma patients (cervical spine considerations)

Physiology:

• Shock physiology (compensated vs. decompensated, cellular oxygen delivery)
• Trauma-induced coagulopathy pathophysiology
• Cardiorespiratory interactions in positive pressure ventilation
• Autonomic responses to hypovolaemia (tachycardia, vasoconstriction)

Pharmacology:

• Tranexamic acid mechanism (antifibrinolytic, plasminogen binding inhibition)
• Induction agents for RSI in trauma (ketamine, etomidate, propofol considerations)
• Calcium gluconate vs. chloride for citrate toxicity reversal
• Prothrombin complex concentrate vs. FFP for coagulopathy

Fellowship Exam Relevance

Written Exam High-Yield Topics:

• ATLS primary survey ABCDE - what to do at each step
• Damage Control Resuscitation principles (permissive hypotension, 1:1:1 ratio, TXA timing)
• Trauma-induced coagulopathy diagnosis and management
• Massive transfusion protocol activation criteria
• E-FAST interpretation and clinical implications
• Time-critical injuries requiring immediate intervention

OSCE Likely Scenarios:

• Resuscitation station: Leading trauma team with multi-casualty scenario
• Procedural station: Chest tube insertion, needle decompression, FAST exam
• Communication station: Breaking bad news to family, handover to receiving trauma team
• Team leadership: Coordinating resuscitation with nursing, surgical, anaesthetic staff

Key Domains Tested:

• Medical Expert: Clinical decision-making, resuscitation priorities
• Communicator: Clear handover, effective team communication
• Leader: Trauma team coordination, resource allocation
• Professional: Ethical decision-making in withdrawal of care

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Key Points

Key Points: The 5 things you MUST know:

1. ATLS ABCDE: Systematic approach to identify and treat life-threatening conditions in order of priority
2. Damage Control Resuscitation: Permissive hypotension (SBP 80-90), balanced 1:1:1 blood product ratio, TXA within 3 hours
3. Massive Transfusion Protocol: Activate with greater than 4 units RBC in 4 hours, use ABC scoring, anticipate coagulopathy
4. E-FAST: Immediate bedside ultrasound to identify hemoperitoneum, hemothorax, pneumothorax, cardiac tamponade
5. Time-Critical Injuries: Tension pneumothorax, massive hemothorax, cardiac tamponade, exsanguinating hemorrhage require immediate intervention

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Epidemiology

Australian/NZ Specific

• Mortality disparity: Indigenous Australians have 2.4x higher trauma mortality
• Rural/remote: 30% of population but 50% of trauma deaths occur outside major centers
• Mechanism: MVA most common (45-55%), falls (25-30%), assault (15-20%)
• Retrieval times: Average 3-6 hours for remote locations vs. below 1 hour metropolitan
• Level I trauma centers: 6 major centers across Australia (Sydney, Melbourne, Brisbane, Perth, Adelaide)

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Pathophysiology

Mechanism

Trauma resuscitation addresses the physiological consequences of severe injury, primarily focusing on:

1. Hemorrhagic Shock: Loss of circulating blood volume leading to tissue hypoperfusion

   • Compensated: Maintains BP via tachycardia, vasoconstriction
   • Decompensated: BP falls, tissue oxygen delivery inadequate
   • Irreversible: Cellular death, multi-organ failure develops

2. Trauma-Induced Coagulopathy (TIC): Immediate coagulopathy occurring before resuscitation

   • Mechanism: Hypoperfusion-induced protein C activation, glycocalyx shedding, endothelial dysfunction
   • Time: Occurs within 30 minutes of injury
   • Effects: Hyperfibrinolysis, factor consumption, platelet dysfunction

3. The Lethal Diamond (expanding from triad):

   Acidosis (pH below 7.2) + Coagulopathy (INR greater than 1.5) + Hypothermia (below 35°C) + Hypocalcemia (ionised Ca below 1.0)
   

Pathological Progression

Injury → Hemorrhage → Hypovolaemia → Tissue Hypoperfusion → Metabolic Acidosis
                                                          ↓
                                                     Endothelial Damage
                                                          ↓
                                              Protein C Activation
                                                          ↓
                                          Trauma-Induced Coagulopathy
                                                          ↓
                                            Further Bleeding
                                                          ↓
                                 -----------------------------------------
                                 ↓                                        ↓
                         Hypothermia                            Hemodilution
                                 ↓                                        ↓
                                 -------------------      Crystalloid Excess
                                                      ↓
                                           Worsening Coagulopathy
                                                      ↓
                                    Death from Exsanguination

Why It Matters Clinically

Understanding this cascade informs all resuscitation decisions:

• Permissive hypotension: Prevents disrupting fragile clots, reduces hemodilution
• 1:1:1 ratio: Replaces consumed factors, addresses TIC early
• Limited crystalloids: Prevents dilutional coagulopathy and acidosis
• Active warming: Prevents hypothermia which worsens bleeding
• Calcium repletion: Addresses citrate toxicity from massive transfusion

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Clinical Approach

Recognition

Triggers for Trauma Resuscitation Activation:

• SBP below 90 mmHg in adult trauma patient
• GCS ≤9
• Penetrating injury to torso, neck, or groin
• Massive external hemorrhage requiring tourniquet or hemostatic dressing
• Positive FAST in unstable patient
• Respiratory distress or failure
• Suspected spinal cord injury with shock
• Pelvic fracture with hemodynamic instability
• ≥2 limbs major amputation or crush injury

Initial Assessment

Primary Survey (ATLS ABCDE)

A - Airway Maintenance with Cervical Spine Protection

• Immediate intervention if airway threatened
• Assume cervical spine injury until cleared
• Indications for immediate intubation:
  • GCS ≤9
  • Inability to maintain airway (maxillofacial trauma, blood, vomit)
  • Hypoxia refractory to oxygen
  • Severe respiratory distress or failure
• Technique: RSI with manual inline stabilization (MILS)
• Cricothyrotomy if cannot intubate, cannot ventilate

B - Breathing and Ventilation

• Assess: Respiratory rate, effort, breath sounds, oxygen saturation
• Immediate interventions:
  • "Tension pneumothorax: Needle decompression (5th ICS, mid-axillary line) followed by chest tube"
  • "Open pneumothorax: Occlusive dressing (3-sided if tension develops)"
  • "Massive hemothorax: Chest tube, autotransfusion if greater than 1500mL initial output"
  • "Flail chest: Pain control, ventilation if severe"
• Target: SpO2 94-98% (higher if TBI), PaCO2 35-45 mmHg

C - Circulation with Hemorrhage Control

• Assess: Pulse, BP, capillary refill, skin colour, temperature
• Immediate interventions:
  • "External hemorrhage: Direct pressure, tourniquet (limb), hemostatic dressing"
  • "Internal hemorrhage: E-FAST, massive transfusion activation"
  • "Pelvic fracture: Pelvic binder"
  • "Shock: Permissive hypotension (SBP 80-90) if no TBI, blood products > crystalloids"
• Vascular access: Two large-bore IVs (14-16G) or intraosseous access

D - Disability (Neurological Status)

• Assess: GCS (E, V, M components), pupillary response, lateralizing signs
• Immediate interventions:
  • Hypoxia/hypotension correction (prevents secondary brain injury)
  • Hyperventilation ONLY if signs of herniation (target PaCO2 30-35 mmHg)
  • Osmotic agents for elevated ICP if indicated
• Target: SBP ≥110 mmHg if TBI present

E - Exposure/Environmental Control

• Full exposure to identify hidden injuries
• Prevent hypothermia:
  • Active warming (Bair Hugger, warmed blankets)
  • Warm all IV fluids and blood products
  • Keep ambient temperature high in resus bay
• Logroll: Check posterior injuries, spine assessment

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

On first glance, assess:

• Alertness: Responsiveness, agitation (hypoxia, hypovolaemia, TBI)
• Work of breathing: Tachypnoea, accessory muscle use, paradoxical breathing
• Perfusion: Skin colour (pale, cyanotic, mottled), temperature (cool peripheries)
• External bleeding: Obvious wounds, dressings soaked with blood
• Position: Tripod, supine, posture suggestive of spinal injury
• Surroundings: Scene clues (e.g., debris position suggests mechanism)

Specific Findings

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound

E-FAST (Extended Focused Assessment with Sonography for Trauma):

1. Subxiphoid Cardiac View

   • Finding: Anechoic pericardial fluid (greater than 1cm posterior to heart)
   • Significance: Cardiac tamponade if hypotensive + distended neck veins + muffled heart sounds
   • Action: Immediate pericardiocentesis or pericardial window

2. Right Upper Quadrant (Morison's Pouch)

   • Finding: Anechoic fluid between liver and right kidney
   • Significance: Intraperitoneal haemorrhage (liver injury most common source)
   • Action: Activate massive transfusion if unstable, prepare for OR

3. Left Upper Quadrant (Splenorenal Recess)

   • Finding: Anechoic fluid between spleen and left kidney
   • Significance: Intraperitoneal haemorrhage (spleen injury most common source)
   • Action: Activate massive transfusion if unstable, prepare for OR

4. Suprapubic (Pouch of Douglas/Retrovesical)

   • Finding: Anechoic fluid in pelvis (most dependent site)
   • Significance: Intraperitoneal haemorrhage, pelvic fracture bleeding
   • Action: Pelvic binder, consider preperitoneal packing/angiography

5. Right Hemithorax

   • Finding: Anechoic pleural fluid
   • Significance: Hemothorax, may require chest tube
   • Action: Chest tube, autotransfusion if greater than 1500mL

6. Left Hemithorax

   • Finding: Anechoic pleural fluid
   • Significance: Hemothorax, may require chest tube
   • Action: Chest tube, autotransfusion if greater than 1500mL

7. Lung Sliding (Both Hemithoraces)

   • Finding: Absence of lung sliding, lung point present
   • Significance: Pneumothorax (lung point is 100% specific)
   • Action: Needle decompression if tension, chest tube if symptomatic

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Management

Immediate Management (First 10 Minutes)

1. Call for trauma team activation (code yellow/code trauma)
2. Simultaneously:
   a. Assess airway, intervene if compromised
   b. Assess breathing, treat tension PTX immediately
   c. Assess circulation, control external bleeding (tourniquet)
   d. Establish large-bore access (2x 14-16G or IO)
3. Attach monitors: ECG, SpO2, NIBP, EtCO2
4. Initiate fluid resuscitation: Blood products > crystalloids
5. Perform E-FAST while team prepares interventions
6. Order immediate blood products (uncrossmatched O-negative)
7. Active warming measures (Bair Hugger, warmed blankets)
8. Administer TXA 1g IV over 10 min (if within 3 hours of injury)
9. Reassess ABCDE continuously
10. Prepare for rapid sequence induction if airway needed

Resuscitation

Airway

Indications for Immediate Intubation:

• GCS ≤9
• Airway obstruction (blood, vomit, facial fractures)
• Hypoxia refractory to supplemental oxygen
• Severe respiratory distress or fatigue
• Need for transport to OR/angiography

RSI in Trauma:

• Pre-oxygenation: 100% O2 for 3-5 minutes (head up 30° if not contraindicated)
• Manual inline stabilization (MILS): Limit cervical spine motion
• Induction agent options:
  • Ketamine 1-2 mg/kg (haemodynamically stable, maintains BP)
  • Etomidate 0.3 mg/kg (cardiovascularly stable, adrenal suppression concern)
  • Propofol 1-2 mg/kg (caution if haemodynamically unstable)
• Paralysis: Rocuronium 1.2 mg/kg or Suxamethonium 1-1.5 mg/kg
• Consider cricoid pressure (controversial, may hinder laryngoscopy)
• Confirm tube placement: ETT waveform capnography, bilateral breath sounds, chest rise

Breathing

Oxygenation Targets:

• SpO2 94-98% (avoid hyperoxia unless TBI)
• If TBI: SpO2 greater than 98%, PaO2 greater than 80 mmHg

Ventilation Targets:

• PaCO2 35-45 mmHg (normocapnia)
• If TBI with herniation signs: PaCO2 30-35 mmHg (temporary hyperventilation)
• Avoid hypocapnia in non-herniating TBI (worsens cerebral ischemia)

Ventilator Settings:

• Mode: VC/AC or PC/AC
• Tidal volume: 6-8 mL/kg (IBW)
• Rate: 12-16 breaths/min
• PEEP: 5-10 cmH2O (avoid in hypovolaemia)
• FiO2: Titrate to SpO2 target

Circulation

Permissive Hypotension:

• Target: SBP 80-90 mmHg or MAP 60-65 mmHg
• Indications: Penetrating trauma, blunt trauma without TBI or spinal cord injury
• Contra-indications: TBI (SBP ≥110), spinal cord injury, pregnant patient
• Rationale: Prevents clot disruption, reduces hemodilution
• Endpoints: Definitive hemorrhage control (surgery/angiography)

Crystalloid Resuscitation (Limited):

• Initial bolus: 1L isotonic crystalloid (Hartmann's, Plasma-Lyte, 0.9% NaCl)
• If patient remains unstable: Transition immediately to blood products
• Avoid: Excessive crystalloid (greater than 2L) worsens coagulopathy, acidosis, dilutes blood products

Blood Product Resuscitation:

• Uncrossmatched O-negative PRBC: First 2-4 units
• Transition to type-specific once available
• Massive transfusion protocol (MTP): Activate when greater than 4 units RBC in 4 hours expected
• 1:1:1 ratio: Plasma : Platelets : PRBCs
• Consider: Whole blood (low-titer O-positive) if available

Calcium Repletion:

• Indication: Massive transfusion (greater than 4 units), ionised Ca below 1.0 mmol/L
• Calcium gluconate 10%: 10 mL IV over 5-10 min (slower onset, less irritant)
• Calcium chloride 10%: 10 mL IV over 5-10 min (faster onset, more irritant, larger Ca2+ load)

Temperature Management:

• Prevent hypothermia (below 35°C) as it worsens coagulopathy
• Active warming: Forced-air blanket, warmed IV fluids, warmed environment
• Target: Maintain core temperature greater than 36°C

Medications

| Drug | Dose | Route | Timing | Notes | |------|------|-------|--------| | Tranexamic Acid | 1g over 10min + 1g infusion over 8h | IV | Within 3 hours of injury (best within 1h) | CRASH-2 trial showed 15% mortality reduction if given early | | O-negative PRBC | 1-2 units initially, then MTP | IV | Immediately for significant bleeding | Uncrossmatched for first 2-4 units | | Fresh Frozen Plasma | 1:1 ratio with PRBCs in MTP | IV | With PRBCs if MTP activated | Thawed plasma takes 20-30 min, use thawed if available | | Platelets | 1 therapeutic dose (6 pack) | IV | 1:1 ratio in MTP | Often limited, may need cryoprecipitate for fibrinogen | | Cryoprecipitate | 10 units | IV | Fibrinogen below 1.5 g/L or ROTEM low FIBTEM | Contains fibrinogen, factor VIII, vWF | | Prothrombin Complex Concentrate | 25-50 IU/kg factor IX | IV | Warfarin reversal, elevated INR in bleeding | Faster than FFP, volume-sparing | | Rocuronium | 1.2 mg/kg | IV | RSI for intubation | Rapid-onset neuromuscular blockade | | Ketamine | 1-2 mg/kg | IV | RSI induction agent | Haemodynamically stable, dissociative anaesthesia | | Etomidate | 0.3 mg/kg | IV | RSI induction alternative | Cardiovascular stability, adrenal suppression | | Morphine/Fentanyl | 2.5-5mg morphine / 25-50μg fentanyl | IV | Analgesia | Titrate to pain, monitor respiratory depression |

Paediatric Dosing

Ongoing Management

After initial stabilization:

1. Reassess ABCDE continuously
2. Repeat E-FAST after resuscitation if initial negative
3. Laboratory monitoring: CBC, coagulation, ABG, lactate q30-60min
4. Imaging: Pan-scan CT if stable, CT angiography if vascular injury suspected
5. Consultations: Trauma surgery, neurosurgery, orthopaedics, interventional radiology
6. Disposition decision: OR, angiography suite, ICU, or ward

Definitive Care

Damage Control Surgery:

• Indication: Severe hypothermia (below 35°C), coagulopathy (INR greater than 1.5), acidosis (pH below 7.2)
• Principles:
  • Control hemorrhage (ligation, packing, shunting)
  • Control contamination (bowel resection, anastomosis delayed)
  • Abdomen left open (vacuum dressing) to prevent abdominal compartment syndrome
• Return to OR: 24-48 hours later for definitive reconstruction when physiology normalises

Angiographic Embolisation:

• Indications: Pelvic fracture bleeding, solid organ (liver, spleen, kidney) bleeding, retroperitoneal haemorrhage
• Pelvic binder: Place before angiography if pelvic fracture present
• Embolic agents: Gelfoam, coils, glue
• Advantages: Less invasive than surgery, can reach surgically inaccessible areas

Definitive Trauma Care:

• Resuscitation complete when: SBP greater than 90, lactate below 2, temperature greater than 36, coagulation normalising
• Transfer: To Level I trauma center if initial stabilization at lower-level facility
• ICU admission: For ventilatory support, haemodynamic monitoring, ongoing transfusion needs
• Rehabilitation: Early mobilisation, physiotherapy, psychological support

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Disposition

Admission Criteria

• Mandatory admission:
  • Any patient requiring blood transfusion
  • Positive FAST with ongoing bleeding
  • Severe head injury (GCS ≤9 or deterioration)
  • Major long bone or pelvic fractures
  • Solid organ injury (liver, spleen, kidney) grades III-V
  • Spinal cord injury
  • Vascular injury requiring repair
  • Thoracic injury requiring chest tube or observation

ICU/HDU Criteria

• ICU Level 3:

  • Mechanical ventilation
  • Massive transfusion protocol active
  • Severe TBI (GCS ≤8)
  • Post-operative monitoring after damage control surgery
  • Haemodynamic instability requiring vasopressors

• HDU Level 2:

  • Chest tube observation
  • Moderate TBI (GCS 9-12)
  • Solid organ injury grades II-III with monitoring needs
  • Continuous cardiac monitoring, frequent blood transfusion

Discharge Criteria

• Safe discharge from ED only if:

  • Normal E-FAST
  • Normal serial examinations
  • GCS 15 with no head injury
  • No major fractures or vascular injuries
  • Normal vital signs (SBP greater than 100, HR below 100, RR 12-20)
  • Accompanied by responsible adult
  • Able to return immediately if deteriorates

• Red flags to return:

  • New or worsening headache, vomiting
  • Drowsiness, confusion, seizure
  • Shortness of breath, chest pain
  • Abdominal pain, distension, vomiting
  • Weakness, numbness, inability to move limbs

Follow-up

• GP letter: Detailed summary of injuries, investigations, management, discharge plan
• Specialist referral: Trauma clinic, orthopaedics, neurosurgery, vascular surgery
• Outpatient imaging: If required (e.g., CT angiography follow-up, MRI spine)
• Rehabilitation: Early physiotherapy, occupational therapy assessment
• Psychological support: PTSD screening, counselling referral

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Special Populations

Paediatric Considerations

Age-Specific Physiology:

• Children compensate better but decompensate rapidly ("tipping point")
• Hypotension is a late sign (loss of 30-40% blood volume)
• Tachycardia is the primary early sign of shock

Airway Differences:

• Larger tongue relative to oral cavity
• Anterior and cephalad larynx
• Narrowest at cricoid (below cords)
• Uncuffed ETT in children below 8 years, cuff in greater than 8 years

Shock Classification (Age-Based):

Fluid Resuscitation:

• Crystalloid: 20 mL/kg bolus (max 2 boluses before blood)
• Blood: 10 mL/kg PRBC
• Permissive hypotension: Age-adjusted SBP targets

Pregnancy

Physiological Changes:

• Blood volume increases 40-50% (uterine blood flow 500-600 mL/min)
• Heart rate increases 10-15 bpm
• BP decreases in second trimester (returns to baseline by term)
• Aortocaval compression in supine position (uterus greater than 20 weeks)

Resuscitation Modifications:

• Permissive hypotension: SBP 100-110 mmHg (higher to maintain uteroplacental perfusion)
• Left lateral tilt (15-30°) or manually displace uterus
• Rh(D) immunoglobulin: Give if Rh-negative mother, Rh-positive blood product exposure
• Fetal monitoring: Once maternal stabilised (priority is maternal resuscitation)

Elderly

Physiological Differences:

• Reduced physiological reserve (comorbidities, polypharmacy)
• Baseline hypertension may mask shock (SBP "normal" may be hypotensive for patient)
• Anticoagulant/antiplatelet use increases bleeding risk
• Reduced cardiac output, renal function, pulmonary reserve

Management Considerations:

• Earlier blood transfusion (lower threshold)
• Lower injury mechanism can cause severe injury (ground-level fall)
• Reversal of anticoagulants: Warfarin (PCC), DOACs (andexanet alfa for apixaban/rivaroxaban, idarucizumab for dabigatran)
• Aggressive temperature management (less thermoregulatory reserve)

Indigenous Health

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Pitfalls & Pearls

Key Points: Clinical Pearls:

1. "Platinum Ten Minutes": First 10 minutes are critical for hemorrhage control (tourniquets, wound packing) - more important than the "Golden Hour"
2. E-FAST sensitivity: 94% specificity for intraperitoneal fluid but misses retroperitoneal haemorrhage - clinical correlation essential
3. ABC Score for MTP activation: Penetrating mechanism (1pt) + SBP ≤90 (1pt) + HR ≥120 (1pt) + Positive FAST (1pt) → Score ≥2 predicts need for massive transfusion
4. TXA timing is critical: Mortality benefit only if given within 3 hours (35% reduction if within 1 hour), no benefit or harm after 3 hours
5. Pelvic fractures bleed 1-2 L: Immediate pelvic binder, consider angiographic embolisation early
6. Fibrinogen is first factor lost: Replenish early (cryoprecipitate or fibrinogen concentrate) when fibrinogen below 1.5 g/L
7. Viscoelastic testing (ROTEM/TEG): Guides goal-directed resuscitation, reduces total blood product use by 25-40%
8. REBOA for Zone III hemorrhage: Consider for pelvic/junctional bleeding when angiography unavailable or delayed
9. Permissive hypotension contraindicated in TBI: Maintain SBP ≥110 mmHg to prevent secondary brain injury
10. Whole blood superiority: If available, low-titer O-positive whole blood is physiologically superior to 1:1:1 component therapy

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Viva Practice

Viva: Stem: "A 32-year-old male is brought in by ambulance following a high-speed motor vehicle accident. He was unrestrained, ejected from vehicle. Vitals: BP 75/45, HR 135, RR 28, SpO2 88% on non-rebreather. GCS 7 (E2, V1, M4). Abdomen is distended and tense. What are your immediate priorities?"

Opening Question: Walk me through your primary survey assessment and interventions in order.

Model Answer: "I would simultaneously assess Airway, Breathing, Circulation, Disability, Exposure while trauma team prepares interventions.

A - Airway: With GCS 7, airway is compromised. I would immediately prepare for RSI. Check for airway obstruction (blood, vomit, facial fractures). Assuming no obstruction, proceed with RSI with manual inline stabilization (MILS) due to possible cervical spine injury.

B - Breathing: SpO2 88% indicates hypoxia. Assess breath sounds, chest rise, tracheal deviation. If absent breath sounds on one side with tracheal deviation, treat immediately as tension pneumothorax with needle decompression (5th ICS, mid-axillary line) followed by chest tube. If bilateral breath sounds present, ensure adequate oxygenation with 100% O2 and prepare for intubation.

C - Circulation: BP 75/45 indicates decompensated shock. Check for external bleeding - control with direct pressure, tourniquet if limb bleeding. Establish two large-bore IVs (14-16G) or intraosseous access. Perform E-FAST immediately - distended, tense abdomen suggests hemoperitoneum. Activate massive transfusion protocol. Place pelvic binder if pelvic fracture suspected. Give tranexamic acid 1g IV over 10 minutes. Initiate blood product transfusion (uncrossmatched O-negative) rather than crystalloids.

D - Disability: GCS 7 indicates severe brain injury. Pupils equal and reactive would be reassuring. With GCS ≤9, intubation is indicated for airway protection and hyperventilation only if signs of herniation. Maintain SBP ≥110 mmHg if TBI to prevent secondary injury.

E - Exposure: Fully expose patient to identify all injuries. Logroll to check for posterior injuries. Immediately initiate active warming measures (Bair Hugger, warmed blankets) to prevent hypothermia which worsens coagulopathy."

Follow-up Questions:

1. What induction agent would you choose for RSI and why?

   • Model answer: Ketamine 1-2 mg/kg is preferred in trauma patients with haemodynamic instability as it maintains cardiovascular stability while providing adequate anaesthesia. Etomidate 0.3 mg/kg is an alternative but may cause adrenal suppression. Propofol would worsen hypotension in this unstable patient.

2. What is your target blood pressure during resuscitation?

   • Model answer: This patient has severe TBI (GCS 7), so permissive hypotension is contraindicated. I would target SBP ≥110 mmHg to maintain cerebral perfusion and prevent secondary brain injury. If there were no TBI, I would use permissive hypotension (SBP 80-90) to prevent clot disruption until surgical hemorrhage control.

3. The patient's E-FAST shows fluid in all abdominal views. What is your next step?

   • Model answer: A positive FAST in a hypotensive patient with tense abdomen indicates intraperitoneal haemorrhage requiring immediate surgical intervention. I would activate trauma surgery team, continue massive transfusion, and transfer patient immediately to operating room for laparotomy and damage control surgery. The abdominal distension and hypotension indicate exsanguinating haemorrhage - time to definitive control is critical.

Discussion Points:

• Importance of simultaneous ABCDE assessment in trauma resuscitation
• Indications for immediate RSI (GCS ≤9, airway compromise, respiratory failure)
• Permissive hypotension vs. blood pressure targets in TBI
• Massive transfusion protocol activation criteria and implementation
• The role of E-FAST in guiding decision-making for operative vs. non-operative management
• Damage control surgery principles vs. definitive repair
• Team communication and closed-loop communication during resuscitation

Viva: Stem: "A 45-year-old female is brought in after being stabbed in abdomen. On arrival: BP 85/50, HR 145, RR 32, SpO2 92%. Abdomen with multiple stab wounds, active bleeding. Massive transfusion protocol has been activated. Discuss your approach to blood product resuscitation."

Opening Question: Explain principles of damage control resuscitation and massive transfusion in this patient.

Model Answer: "Damage control resuscitation aims to prevent and treat lethal diamond (acidosis, coagulopathy, hypothermia, hypocalcemia) while achieving hemorrhage control. In this patient with penetrating abdominal trauma and haemodynamic instability, I would implement:

Permissive Hypotension: Target SBP 80-90 mmHg (MAP 60-65) to maintain organ perfusion while preventing clot disruption until surgical hemorrhage control. Avoid aggressive crystalloid resuscitation - limit to 1L maximum before transitioning to blood products.

Balanced Blood Product Ratio: 1:1:1 ratio of Plasma : Platelets : PRBCs to mimic whole blood and replace clotting factors and platelets early. Start with uncrossmatched O-negative PRBC (2-4 units), transition to type-specific when available. Activate massive transfusion protocol as she likely requires greater than 4 units in 4 hours.

Early Antifibrinolytic: Tranexamic acid 1g IV over 10 minutes now (within 3 hours of injury) followed by 1g infusion over 8 hours. CRASH-2 trial shows 35% mortality reduction if given within 1 hour.

Immediate Surgical Intervention: Penetrating abdominal trauma with haemodynamic instability requires immediate laparotomy for hemorrhage control. Prepare for damage control surgery - focus on ligation, packing, controlling contamination rather than definitive reconstruction.

Monitoring and Adjuncts:

• E-FAST: Confirm intraperitoneal haemorrhage (expected positive)
• Laboratory: CBC, coagulation panel, fibrinogen, ionised calcium q30-60min
• Viscoelastic testing (ROTEM/TEG) if available to guide goal-directed transfusion
• Calcium repletion: Give calcium gluconate 10% or calcium chloride 10% if ionised Ca below 1.0 mmol/L (expected with massive transfusion)

Transfusion Strategy:

• MTP cooler typically contains: 6 units PRBC, 6 units FFP, 1 dose platelets (1:1:1)
• Additional: Cryoprecipitate if fibrinogen below 1.5 g/L or low FIBTEM on ROTEM
• Consider prothrombin complex concentrate if on warfarin (reversal) or elevated INR with bleeding"

Follow-up Questions:

1. What are the criteria for activating a massive transfusion protocol?

   • Model answer: ABC score ≥2 (Assessment of Blood Consumption): A-ssessment (penetrating mechanism), B-lood pressure (SBP ≤90), C-ardiac rate (HR ≥120), D-FAST (positive FAST). Each 1 point, ≥2 predicts need for massive transfusion (greater than 4 units in 24 hours or greater than 10 units in 24 hours). Other criteria: Clinical judgement of ongoing bleeding, anticipated greater than 4 units in 4 hours, base deficit < -6, lactate greater than 5.

2. The patient has received 8 units of PRBC and her INR is 2.1. What is your management?

   • Model answer: Elevated INR in context of massive transfusion indicates dilutional coagulopathy and trauma-induced coagulopathy. Options: FFP (typically in 1:1:1 ratio, likely already being given), or Prothrombin Complex Concentrate (PCC) 25-50 IU/kg factor IX. PCC acts faster (minutes vs. 30 min for FFP), volume-sparing, and contains factors II, VII, IX, X. Given ongoing bleeding and INR 2.1, I would administer PCC immediately. Continue MTP, check fibrinogen (likely low), consider cryoprecipitate. If ROTEM available: prolonged EXTEM CT indicates need for FFP or PCC.

3. What complications should you monitor for with massive transfusion?

   • Model answer: Multiple complications to monitor:
     • Citrate toxicity: Hypocalcaemia (ionised Ca below 1.0 mmol/L) - causes hypotension, cardiac dysfunction, worsens coagulopathy. Treat with calcium gluconate/chloride.
     • Transfusion-associated circulatory overload (TACO): Pulmonary oedema from volume overload. Monitor respiratory status, consider diuretics.
     • Transfusion-related acute lung injury (TRALI): Non-cardiogenic pulmonary oedema within 6 hours of transfusion. Supportive care.
     • Hypothermia: From cold blood products if not warmed - actively warm all products.
     • Hyperkalaemia: From stored red cell lysate. Monitor ECG, potassium levels.
     • Acid-base disturbance: Stored blood has acidic pH but citrate metabolism produces alkalosis.
     • Dilutional thrombocytopenia: Platelets diluted, monitor platelet count.
     • Haemolytic transfusion reaction: Fever, hypotension, dark urine. Stop transfusion, treat.

Discussion Points:

• PROPPR trial evidence for 1:1:1 ratio (faster hemostasis, fewer exsanguination deaths)
• CRASH-2 trial evidence for tranexamic acid (timing critical)
• Trauma-induced coagulopathy pathophysiology (hypoperfusion, protein C activation)
• The transition from crystalloid-based to blood product-based resuscitation (ATLS 10th Edition)
• Goal-directed resuscitation using viscoelastic testing (ROTEM/TEG) vs. fixed ratios
• Whole blood advantages (physiologic, reduces volume, more efficient)
• Damage control surgery indications (lethal diamond, physiologic exhaustion)
• Team communication during massive transfusion (closed-loop, role clarity)

Viva: Stem: "A 28-year-old male presents after being struck by a car. On assessment: BP 70/45, HR 130, RR 26, SpO2 94%. Obvious deformity of right thigh (femur fracture). E-FAST shows fluid in pelvic view. Pelvic X-ray shows disruption of right sacroiliac joint. How do you manage this patient?"

Opening Question: What are your priorities in managing a patient with pelvic fracture and haemorrhagic shock?

Model Answer: "Management of pelvic fracture with haemorrhagic shock requires immediate multidisciplinary intervention focused on three simultaneous approaches: non-operative haemorrhage control, massive transfusion, and definitive intervention.

Immediate Interventions (simultaneous):

1. Pelvic Binder: Apply immediately (within 5 minutes) to reduce pelvic volume and tamponade venous bleeding. Position over greater trochanters, not sacrum. This is critical as pelvic fractures can bleed 1-2 litres from venous plexus and arterial injury.
2. Massive Transfusion Protocol: Activate immediately. Pelvic fractures are common cause of massive transfusion. Use 1:1:1 ratio, limit crystalloids to 1L maximum.
3. E-FAST Confirmation: Fluid in pelvic view (most dependent) suggests intraperitoneal or retroperitoneal bleeding. Positive FAST in unstable patient indicates need for surgical/angiographic intervention.
4. External Hemorrhage Control: Direct pressure, tourniquet if limb bleeding (femur fracture less likely to have external bleeding but assess carefully).

Diagnostic Imaging:

• Pelvic X-ray: Already obtained, shows right sacroiliac joint disruption (likely APC or VS type injury). Guides binder placement.
• CT Angiography: If patient can be stabilised (SBP greater than 90), obtain pelvic CT angiography to identify arterial bleeding (superior gluteal, internal pudendal, obturator arteries). CT angiography has high sensitivity for active arterial extravasation.
• If patient remains unstable: Direct angiography/embolisation OR preperitoneal packing OR external fixation.

Hemorrhage Control Options:

• Angiographic Embolisation: First-line for arterial bleeding from pelvic fracture. Can embolise both internal iliac arteries if bilateral injury.
• Preperitoneal Pelvic Packing: Surgical option if angiography unavailable or delayed. Retroperitoneal packing controls venous and some arterial bleeding.
• External Fixation: Provides mechanical stability, reduces pelvic volume, adjunct to other measures.

Permissive Hypotension: Target SBP 80-90 mmHg (MAP 60-65) as no TBI. Maintain enough perfusion for vital organs while reducing ongoing bleeding until definitive hemorrhage control.

Resuscitation Adjuncts:

• Tranexamic acid 1g IV over 10 minutes (within 3 hours)
• Calcium repletion if ionised Ca below 1.0 mmol/L
• Active warming
• Fibrinogen replacement if below 1.5 g/L (cryoprecipitate 10 units or fibrinogen concentrate)

Definitive Care:

• Arrange for angiography suite or OR immediately
• Orthopaedic consultation for definitive pelvic fixation
• ICU admission post-intervention"

Follow-up Questions:

1. How does type of pelvic fracture influence bleeding pattern?

   • Model answer: Pelvic fracture patterns predict bleeding sources:
     • Lateral compression (LC): Less bleeding, mainly from cancellous bone, some venous
     • Anteroposterior compression (APC): More bleeding, sacroiliac disruption causes significant venous bleeding from presacral plexus and potential arterial injury
     • Vertical shear (VS): Highest bleeding risk, sacroiliac disruption with vertical shear damages major arterial branches
     • Combined mechanical (CM): Variable bleeding depending on components

2. The patient stabilises after pelvic binder but SBP drops to 70/45 when binder is temporarily removed for CT. What do you do?

   • Model answer: This indicates ongoing bleeding that is controlled by binder. Options:
     • Proceed directly to angiography: If patient is too unstable for CT, take directly to interventional radiology for embolisation. CT is for stable patients to identify bleeding site.
     • Keep binder in place: Don't remove if causes instability. Can perform angiography with binder in place (remove temporarily if needed for access).
     • Consider preperitoneal packing: If angiography unavailable or delayed (greater than 90 min), proceed to OR for retroperitoneal packing.
     • External fixation: Provide mechanical stability while definitive control being arranged. The clinical status (unstable when binder off) takes precedence over imaging - proceed to definitive intervention.

3. What is role of REBOA (Resuscitative Endovascular Balloon Occlusion of Aorta) in pelvic trauma?

   • Model answer: REBOA is an emerging option for non-compressible torso haemorrhage below diaphragm, including severe pelvic bleeding. In Zone III (infrarenal aorta), REBOA can occlude aortic flow to pelvis/lower limbs, reducing haemorrhage while providing increased perfusion to heart/brain. Indications: Patient in profound shock (SBP below 60-70) where time to angiography/packing is greater than 60 minutes. REBOA provides temporary control (30-60 min max occlusion time) - must be followed by definitive intervention (embolisation, packing). Compared to resuscitative thoracotomy, REBOA is less invasive and more appropriate for pelvic/abdominal bleeding without chest trauma. UK-REBOA trial showed mixed results - patient selection and expertise critical. Not yet first-line, consider when other options unavailable or delayed.

Discussion Points:

• ABC score for MTP activation in pelvic fractures
• Pelvic binder application technique and timing (critical first intervention)
• Angiography vs. preperitoneal packing vs. external fixation (choice depends on resources, availability, expertise)
• Whole blood advantages in pelvic trauma (often requires massive transfusion)
• The concept of "non-compressible torso haemorrhage" (NCTH)
• REBOA as emerging technology for NCTH control
• Multidisciplinary approach (trauma surgery, orthopaedics, interventional radiology)
• Timing of definitive orthopaedic fixation (vs. initial damage control)

Viva: Stem: "A 25-year-old male falls 5 metres from a ladder. On arrival: BP 100/60, HR 95, RR 18, SpO2 96% on room air. GCS 8 (E2, V2, M4). Pupils equal 3mm, reactive. Right hemithorax has decreased breath sounds. Abdomen is soft, non-tender. Right leg is externally rotated, shortened, with thigh swelling. Discuss your management."

Opening Question: How do you balance competing priorities of TBI management and haemorrhage control in a polytrauma patient with head injury and chest/limb trauma?

Model Answer: "This patient presents with complex competing priorities: Severe TBI (GCS 8) requiring higher blood pressure targets vs. potential haemorrhage from chest injury and femur fracture. My approach follows ABCDE with modifications for TBI:

A - Airway: With GCS 8, airway protection required. Prepare for RSI with MILS (cervical spine risk). Induction: Ketamine 1-2 mg/kg (maintains haemodynamics) or etomidate 0.3 mg/kg. Avoid hypotension from induction agents.

B - Breathing: Decreased breath sounds on right suggests hemothorax or pneumothorax. Immediate intervention:

• Needle decompression (5th ICS, mid-axillary line) if tension pneumothorax suspected (hypotension, tracheal deviation)
• Chest tube insertion (4th-5th ICS, mid-axillary line) for hemothorax
• Target: SpO2 greater than 98%, PaO2 greater than 80 mmHg (higher than usual for TBI), PaCO2 35-45 mmHg (avoid hypocapnia)

C - Circulation: This is where competing priorities require balance:

• External bleeding: Assess for obvious bleeding - control with direct pressure, tourniquet if needed
• E-FAST: Immediate - assess for intraperitoneal haemorrhage, pericardial fluid, confirm hemothorax
• Blood pressure target: SBP ≥110 mmHg (higher than permissive hypotension of 80-90). TBI requires adequate cerebral perfusion pressure. Higher target may increase bleeding but secondary brain injury is more dangerous
• Femur fracture: Likely causing significant pain, blood loss (1-2 units). Splint to reduce pain, ongoing bleeding
• Fluid resuscitation: Start with 1L crystalloid, transition quickly to blood products if needed. Avoid aggressive fluids causing cerebral oedema

D - Disability:

• Monitor GCS continuously (E, V, M components separately)
• Pupils: Equal and reactive is reassuring, repeat assessment
• Avoid hypoxia and hypotension - most important for TBI outcome
• Consider early CT head once stabilised

E - Exposure:

• Full assessment, look for hidden injuries
• Logroll for spine assessment
• Active warming

Diagnostic Plan:

• CT head: To identify intracranial haemorrhage, contusion, diffuse axonal injury
• CT chest: Characterise hemothorax, pneumothorax, pulmonary contusion
• CT abdomen/pelvis: Exclude intra-abdominal injury
• Femur X-ray: Confirm fracture, plan fixation

Resuscitation Balance:

• TBI priority: SBP ≥110, SpO2 greater than 98%, normocapnia, avoid hypoxia/hypotension
• Haemorrhage concern: Hemothorax (drain with chest tube, autotransfuse if greater than 1500mL), femur fracture (splint, plan ORIF), monitor E-FAST for abdominal bleeding
• Massive transfusion: Activate if evidence of ongoing haemorrhage despite SBP ≥110
• Tranexamic acid: Give 1g IV over 10 minutes if within 3 hours (benefit in TBI and bleeding)"

Follow-up Questions:

1. Why is a higher blood pressure target needed in TBI patients?

   • Model answer: TBI patients are vulnerable to secondary brain injury from cerebral hypoperfusion. Cerebral perfusion pressure (CPP) = MAP - ICP. In TBI, ICP may be elevated. To maintain adequate CPP (greater than 60-70 mmHg), we need higher MAP (hence higher SBP target). SBP ≥110 mmHg is ATLS recommendation. Hypotension (SBP below 90) doubles mortality in TBI. Higher target may increase bleeding risk, but secondary brain injury causes worse outcomes than moderate haemorrhage. This is one situation where permissive hypotension is contraindicated.

2. When would you hyperventilate this patient?

   • Model answer: Hyperventilation is a temporary measure to lower ICP when signs of cerebral herniation are present. Signs include: Unequal (dilated, non-reactive) pupil, posturing (decerebrate/decorticate), Cushing's triad (bradycardia, hypertension, irregular respirations), sudden GCS drop. In this scenario, if pupils become unequal or patient develops posturing, I would target PaCO2 30-35 mmHg temporarily. Avoid routine hyperventilation in TBI - it causes cerebral vasoconstriction, reduces cerebral blood flow, and can worsen ischemic brain injury. Hyperventilation is a bridge to definitive ICP control (mannitol, hypertonic saline, surgical decompression).

3. CT head shows right subdural haematoma with 5mm midline shift. GCS remains 8. What is your management?

   • Model answer: Subdural haematoma with 5mm midline shift in patient with GCS 8 requires neurosurgical consultation. Management options:
     • Conservative: If GCS stable, no herniation signs, below 10mm shift, consider ICU monitoring with repeat CT, ICP monitor if needed. Close neurosurgical involvement.
     • Surgical evacuation: Indications include: GCS ≤8 with deterioration, greater than 10mm midline shift, significant mass effect, neurological deficits. 5mm shift is borderline, but GCS 8 without improvement is concerning. Discuss urgently with neurosurgeon - likely surgical evacuation.
     • Medical management: Elevate head of bed 30°, keep head midline, maintain SBP ≥110, avoid hyperosmolar agents (mannitol 0.5-1 g/kg IV if herniation signs), hypertonic saline 3% (250 mL bolus if indicated).
     • ICP monitoring: Consider if surgical decision delayed, patient at risk of elevated ICP. Allows goal-directed ICP management.
     • Trauma management priority: Address chest hemothorax, femur fracture in coordination with neurosurgery. Balance bleeding risk with TBP target.

   In this case, likely proceed to OR for craniotomy and SDH evacuation while coordinating orthopaedic for femur fixation (can be done after craniotomy if stable).

Discussion Points:

• TBI-specific airway/breathing/circulation targets (higher BP targets, SpO2 greater than 98%)
• Permissive hypotension contraindications (TBI, spinal cord injury, pregnancy)
• Hyperventilation indications and risks (temporary measure for herniation)
• Secondary brain injury prevention (avoid hypoxia, hypotension, hyperglycaemia, seizures)
• Mass lesion evacuation criteria (midline shift, GCS, deterioration)
• Multidisciplinary coordination (neurosurgery, trauma surgery, orthopaedics)
• Timing of femur fracture fixation in TBI (early vs. delayed)
• ICP monitoring indications and management

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OSCE Scenarios

Station 1: Trauma Team Leader - Multi-Casualty Incident

Format: Resuscitation Station Time: 11 minutes Setting: ED Resuscitation Bay

Candidate Instructions:

You are team leader in Emergency Department. Two patients arrive simultaneously from a motor vehicle accident. You must prioritise and coordinate management of both patients, delegating tasks appropriately to your team members (nurse, registrar, orderly). You have access to E-FAST, rapid infuser, and standard resuscitation equipment. Focus on patient 1 first, then patient 2 as indicated.

Patient 1: 35-year-old male, ejected from vehicle at high speed. BP 70/40, HR 145, RR 30, SpO2 88%. GCS 6 (E1, V1, M4). Abdomen is distended and tense.

Patient 2: 28-year-old female, restrained passenger. BP 105/70, HR 95, RR 18, SpO2 97% on room air. GCS 15. Right forearm deformity with visible fracture. Complains of abdominal pain (right upper quadrant tenderness). Pelvic stable.

Examiner Instructions:

• Patient 1 is priority due to haemodynamic instability and altered GCS
• Patient 2 is stable but has potentially serious intra-abdominal injury
• Assess: Primary survey of Patient 1, immediate interventions, team leadership, delegation, and reassessment
• Candidate should then attend to Patient 2 once Patient 1 stabilised
• Evaluate: Systematic approach, prioritisation, communication, clinical judgement

Marking Criteria:

Expected Standard:

• Pass: ≥12/19
• Key discriminators:
  • Must identify Patient 1 as immediate priority
  • Must recognise GCS ≤9 requires RSI
  • Must activate massive transfusion for Patient 1
  • Must use permissive hypotension appropriately (NOT in TBI, SBP ≥110 required)
  • "Must delegate tasks clearly (nurse: access/fluids, registrar: airway/lines, orderly: equipment)"
  • Must reassess Patient 1 after interventions
  • Must provide appropriate care for Patient 2 (not abandon entirely)

Common Errors:

• Getting distracted by Patient 2 while Patient 1 deteriorates
• Forgetting MILS during RSI
• Using permissive hypotension in TBI (contraindicated)
• Not activating massive transfusion early
• Poor team leadership (doing tasks instead of delegating)
• Forgetting to reassess ABCDE
• Not providing analgesia to Patient 2 (stable patient still requires comfort)

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Station 2: Procedural - E-FAST and Needle Decompression

Format: Procedural/Examination Station Time: 11 minutes Setting: ED Resuscitation Bay with ultrasound machine and chest tube tray

Candidate Instructions:

You are assessing a trauma patient who has sustained blunt chest trauma. Perform an E-FAST examination to identify life-threatening conditions. Then, based on your findings, perform any indicated immediate interventions. You have 11 minutes. Explain your thought process and findings to the examiner as you proceed.

Patient Scenario: Simulated patient with chest trauma model. Findings:

• Right hemithorax: Absent breath sounds, decreased chest wall movement, hyperresonant percussion
• Left hemithorax: Breath sounds present, normal
• Trachea: Deviated to left
• Neck veins: Distended
• Oxygen saturation: 85% on 15L O2
• Blood pressure: 75/50
• Heart rate: 135

Examiner Instructions:

• Patient has clinical signs of tension pneumothorax on right side
• E-FAST should confirm absence of lung sliding and presence of lung point
• Candidate should recognise tension pneumothorax and perform immediate needle decompression
• Evaluate: E-FAST technique, interpretation, procedural skill, patient safety

Marking Criteria:

Expected Standard:

• Pass: ≥12/19
• Key discriminators:
  • Must recognise tension pneumothorax clinically (time-critical, don't delay for E-FAST)
  • Must perform needle decompression promptly (life-saving)
  • Must use correct anatomical location (5th ICS mid-axillary line, NOT 2nd ICS)
  • Must use appropriate needle length (5-8cm, standard 14G may be too short in obese patients)
  • Must assess response to intervention
  • E-FAST is adjunct, should not delay decompression if tension PTX clinically obvious

Common Errors:

• Delaying decompression to complete full E-FAST (tension PTX is clinical diagnosis)
• Using 2nd ICS location (outdated, 5th ICS mid-axillary line recommended in ATLS 10th)
• Using needle too short (14G 2" catheter may not reach pleural space in obese patients)
• Not assessing response to decompression
• Forgetting to prepare for chest tube thoracostomy after decompression
• Inadequate E-FAST technique (poor image quality, missing views)
• Not recognising lung point (100% specific for pneumothorax)

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Station 3: Communication - Breaking Bad News to Family

Format: Communication Station Time: 11 minutes Setting: Relatives' Room (quiet, private space)

Candidate Instructions:

You are emergency doctor managing a 42-year-old male patient who has sustained severe injuries in a motor vehicle accident. The patient has been pronounced dead after resuscitative efforts in the emergency department. The patient's wife and 18-year-old son are waiting in the relatives' room and are expecting to see him. You must inform them of his death. You have 11 minutes.

Patient Details:

• Name: John Smith
• Age: 42
• Mechanism: High-speed MVA, head-on collision
• Injuries: Massive intracranial haemorrhage, multiple rib fractures, hemothorax, liver laceration
• Resuscitation: 45 minutes of CPR, emergency thoracotomy performed, massive transfusion (12 units blood)
• Outcome: Pronounced dead despite maximal intervention

Family Details:

• Wife: Sarah Smith, 40 years old, pregnant (12 weeks)
• Son: Michael Smith, 18 years old
• Support: Aunt also present (witnessing breaking bad news)
• Cultural background: Non-Indigenous Australian

Actor/Patient Brief:

• Wife: Distraught, disbelieving, asking "is he really gone?", wanting to see him immediately, worried about being pregnant and stress
• Son: Initially in shock, quiet, later becomes angry ("the doctors should have done more")
• Aunt: Trying to support, asks questions about what happened

Examiner Instructions:

• Candidate should use appropriate breaking bad news framework (SPIKES or similar)
• Assess: Introduction, setting, information delivery, responding to emotions, answering questions, providing support, follow-up
• Family will react with disbelief, anger, grief
• Candidate should be empathetic, honest, supportive, while maintaining professional boundaries

Marking Criteria:

Expected Standard:

• Pass: ≥12/19
• Key discriminators:
  • Must use clear language ("died" or "dead" not "passed away" or "gone")
  • Must warn of bad news before delivering ("I have some very sad news")
  • Must allow silence and emotion (don't rush)
  • Must validate emotions ("This must be very difficult"
  • "I can see how much you loved him")
  • Must answer questions honestly but not overly graphic
  • Must discuss viewing of body and offer accompaniment
  • Must offer follow-up support (social work, chaplaincy, grief counselling)

Common Errors:

• Using euphemisms ("he's passed"
  • "he didn't make it") which can be confusing
• Rushing through conversation
• Not allowing silence or cutting off emotional expression
• Providing excessive graphic detail about injuries/procedures
• Not offering to accompany family to see body
• Ignoring son's anger (dismissing rather than validating)
• Not checking understanding or asking if they have questions
• Not arranging follow-up support
• Blaming or defensive ("we did everything we could" can sound defensive - focus on "we provided all appropriate treatment")

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SAQ Practice

Question 1 (10 marks)

Stem: A 28-year-old male is brought in after being stabbed in left chest. On arrival: BP 75/45, HR 140, RR 32, SpO2 88% on non-rebreather. Left chest wound is between anterior and mid-axillary line in 4th intercostal space. Neck veins are distended, tracheal deviated to right. No breath sounds on left side.

Question: Describe your immediate management of this patient, including specific interventions and rationale.

Model Answer:

Immediate Management (10 marks):

1. Recognise tension pneumothorax (1 mark):

   • Classic triad: Hypotension, distended neck veins, tracheal deviation to contralateral side
   • Absent breath sounds on affected side
   • Life-threatening, requires immediate intervention

2. Needle decompression (2 marks):

   • Location: 5th intercostal space, mid-axillary line (ATLS 10th Ed recommendation)
   • Needle: 14G or larger, 5-8cm length (longer for obese patients)
   • Technique: Insert superior to rib (neurovascular bundle inferior), until pleural puncture felt, listen for rush of air
   • Alternative location if mid-axillary not accessible: 2nd ICS mid-clavicular line (less preferred but acceptable)

3. Chest tube thoracostomy (2 marks):

   • Indicated after needle decompression for definitive management
   • Size: Large-bore (32-36 French) for traumatic haemothorax
   • Location: 4th or 5th ICS, mid-axillary line
   • Technique: Blunt dissection to pleura, insert tube, clamp until connected to underwater seal
   • Monitor output: If greater than 1500mL initial or ongoing greater than 200mL/hour, require thoracotomy

4. Massive transfusion activation (1 mark):

   • Penetrating chest trauma with haemodynamic instability
   • ABC score likely ≥2 (penetrating mechanism 1pt, SBP ≤90 1pt, HR ≥120 1pt, positive FAST 0pt if chest decompressed before FAST performed)
   • Activate MTP with 1:1:1 ratio

5. Analgesia (1 mark):

   • Chest pain from injury and chest tube
   • IV opioids (morphine or fentanyl) titrated to effect, monitor respiratory depression

6. E-FAST (1 mark):

   • Confirm hemothorax, check for pericardial fluid (cardiac tamponade risk with penetrating injury)
   • May identify additional injuries

7. Tranexamic acid (1 mark):

   • 1g IV over 10 minutes (if within 3 hours of injury)
   • Reduces mortality from bleeding

8. Definitive care (1 mark):

   • Urgent thoracotomy for ongoing bleeding greater than 1500mL or haemodynamic instability
   • Video-assisted thoracoscopic surgery (VATS) for control of intercostal vessel bleeding
   • Transfer to OR/ICU as indicated

Examiner Notes:

• Accept: 2nd ICS mid-clavicular line for needle decompression (older teaching, still acceptable if 5th ICS not accessible)
• Accept: Analgesia can be local anaesthetic infiltration around chest tube site
• Do not accept: Delaying needle decompression to obtain chest X-ray
• Do not accept: Using 2nd ICS mid-clavicular line as first choice (5th ICS mid-axillary line is now recommended)
• Do not accept: Not checking for cardiac tamponade (concomitant injury common in penetrating chest trauma)
• Bonus: Mentioning preparation for resuscitative thoracotomy if patient arrests

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Question 2 (8 marks)

Stem: You are activating a Massive Transfusion Protocol for a 38-year-old female with severe pelvic fracture after being struck by a vehicle. The massive transfusion protocol cooler has arrived containing blood products.

Question: List components of a typical Massive Transfusion Protocol cooler and describe 1:1:1 ratio principle.

Model Answer:

Massive Transfusion Protocol Cooler Components (4 marks):

1. Packed Red Blood Cells (PRBC) (1 mark):

   • 6 units O-negative (uncrossmatched) or type-specific if known
   • Packed, leukoreduced, CMV-negative for trauma patients
   • Stored at 4°C, must be warmed before administration

2. Fresh Frozen Plasma (FFP) (1 mark):

   • 6 units (or equivalent volume to match 6 PRBCs)
   • Contains all clotting factors (II, V, VII, VIII, IX, X, XI, XIII) and fibrinogen
   • Thawed FFP takes 20-30 min, pre-thawed units available in some centres
   • AB plasma preferred (universal donor)

3. Platelets (1 mark):

   • 1 apheresis unit (equivalent to 6 random donor platelet units)
   • Typically added at ratio to achieve 1:1:1 with PRBC and plasma
   • Stored at room temperature, short shelf life (5-7 days)
   • HLA/HPA-matched if previously alloimmunised

4. Optional Additional Products (may be included):

   • Cryoprecipitate: 10 units (contains concentrated fibrinogen, factor VIII, vWF)
   • Calcium gluconate/chloride: 10 mL 10% solution (for citrate toxicity)
   • Whole blood: Some centres now provide low-titer O-positive whole blood (LTOWB)

1:1:1 Ratio Principle (4 marks):

1. Definition (1 mark):

   • Ratio of 1 unit Plasma : 1 unit Platelets : 1 unit PRBCs
   • Approximates composition of whole blood
   • Aims to replace clotting factors and platelets simultaneously with red cells

2. Evidence Base (1 mark):

   • PROPPR trial (Holcomb et al., JAMA 2015, PMID: 25647203)
   • 680 patients, compared 1:1:1 vs 1:1:2 ratios
   • No significant difference in 24-hour or 30-day mortality
   • BUT: 1:1:1 group achieved hemostasis faster (86% vs 78%, p=0.006)
   • Fewer deaths from exsanguination in 1:1:1 group (9.2% vs 14.6%, p=0.03)

3. Rationale (1 mark):

   • Addresses trauma-induced coagulopathy early
   • Prevents dilutional coagulopathy from massive red cell transfusion
   • Replaces platelets which are diluted and consumed
   • More physiologic than 1:1:2 or crystalloid-based resuscitation

4. Implementation (1 mark):

   • Activate when ABC score ≥2 (Assessment of Blood Consumption)
   • Continue until patient stabilises or surgical hemorrhage control achieved
   • Viscoelastic testing (ROTEM/TEG) can guide goal-directed therapy
   • Some centres now using whole blood (naturally 1:1:1) which reduces volume and administrative complexity

Examiner Notes:

• Accept: 1:1:1:1 if including cryoprecipitate (fibrinogen)
• Accept: MTP cooler contents may vary by institution, core principle is balanced resuscitation
• Accept: Whole blood (LTOWB) is increasingly replacing 1:1:1 component therapy where available
• Do not accept: 1:1:2 ratio as preferred (outdated, 1:1:1 is current standard)
• Do not accept: Starting with crystalloids before blood products (ATLS 10th Ed emphasises early blood)
• Bonus: Mentioning that 1:1:1 may not be needed if ROTEM/TEG-guided (goal-directed therapy)

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Question 3 (6 marks)

Stem: You are managing a 22-year-old male with severe traumatic brain injury after a fall from height. GCS is 5 (E1, V1, M3). Current blood pressure is 85/55, heart rate 110.

Question: Outline key components of TBI-specific resuscitation and explain why a higher blood pressure target is required compared to standard trauma resuscitation.

Model Answer:

TBI-Specific Resuscitation Components (3 marks):

1. Airway Management (0.5 marks):

   • Immediate intubation (RSI with MILS) for GCS ≤9
   • Induction agents: Ketamine preferred (maintains haemodynamics) or etomidate
   • Avoid hypotension during induction

2. Breathing/Ventilation (0.5 marks):

   • Target SpO2 greater than 98% (higher than 94-98% for non-TBI trauma)
   • Target PaCO2 35-45 mmHg (normocapnia)
   • Hyperventilation ONLY if signs of herniation (PaCO2 30-35 mmHg temporarily)
   • Avoid routine hyperventilation (causes cerebral vasoconstriction, worsens ischemia)

3. Circulation - Blood Pressure Target (1 mark):

   • Target SBP ≥110 mmHg (higher than permissive hypotension of 80-90)
   • Critical to maintain cerebral perfusion pressure (CPP = MAP - ICP)
   • Hypotension (SBP below 90) doubles mortality in TBI
   • Use blood products early, limit crystalloids to prevent cerebral oedema

4. Hypertonic Osmotic Therapy (0.5 marks):

   • Mannitol 0.5-1 g/kg IV for signs of elevated ICP or herniation
   • Hypertonic saline 3% (250 mL bolus) as alternative
   • Reduces cerebral oedema, lowers ICP

5. Seizure Prophylaxis (0.5 marks):

   • Consider levetiracetam or phenytoin to prevent post-traumatic seizures
   • Seizures worsen secondary brain injury

Rationale for Higher Blood Pressure Target (3 marks):

1. Cerebral Perfusion Pressure (CPP) (1 mark):

   • CPP = MAP - ICP
   • In TBI, ICP is often elevated due to haemorrhage, oedema, mass effect
   • To maintain adequate CPP (greater than 60-70 mmHg), higher MAP (hence higher SBP) is required
   • If CPP below 50-60 mmHg, cerebral ischemia develops, worsening secondary brain injury

2. Prevention of Secondary Brain Injury (1 mark):

   • Primary injury occurs at time of trauma
   • Secondary injury develops over hours-days from hypoxia, hypotension, hyperglycaemia, seizures
   • Hypotension is most preventable cause of secondary brain injury
   • Adequate CPP prevents ischemic neuronal death

3. Autoregulation Impairment (1 mark):

   • Normal brain has autoregulation maintaining constant cerebral blood flow over MAP range 50-150
   • In TBI, autoregulation is impaired or lost
   • Cerebral blood flow becomes pressure-passive: falls if MAP falls, increases if MAP rises
   • Therefore, higher MAP (SBP ≥110) needed to ensure adequate cerebral blood flow
   • Permissive hypotension (SBP 80-90) would cause cerebral ischemia in TBI with impaired autoregulation

Examiner Notes:

• Accept: SBP 100-110 as reasonable target (guidelines vary slightly)
• Accept: Target MAP greater than 80 mmHg (equivalent to SBP ≥110)
• Do not accept: Permissive hypotension in TBI (contraindicated)
• Do not accept: SBP 90 as adequate for TBI (too low, risks cerebral ischemia)
• Do not accept: Hyperventilation as routine management (only for herniation)
• Bonus: Mentioning ICP monitoring indications
• Bonus: Mentioning avoiding hyperglycaemia (maintain glucose 6-10 mmol/L)

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Question 4 (8 marks)

Stem: A 55-year-old male presents after being struck by a motor vehicle while walking. On examination: BP 90/60, HR 120, RR 22, SpO2 95%. Abdomen tender, distended. Pelvic X-ray shows left sacroiliac joint disruption. You perform E-FAST which shows fluid in pelvic view only.

Question: Describe your management of this patient with pelvic fracture and suspected intraperitoneal bleeding, including role of external haemorrhage control measures.

Model Answer:

Management of Pelvic Fracture with Suspected Bleeding (8 marks):

1. Immediate Haemorrhage Control (2 marks):

   • Pelvic Binder Application (1 mark):
     • Apply immediately (within 5 minutes) to reduce pelvic volume, tamponade venous bleeding
     • Position over greater trochanters (NOT sacrum), correct tension
     • Can reduce pelvic volume up to 25%, controlling venous and some arterial bleeding
   • External Bleeding Assessment (1 mark):
     • Assess for overt external bleeding (wounds, lacerations)
     • Control with direct pressure, tourniquet if limb bleeding

2. Massive Transfusion Protocol Activation (1.5 marks):

   • ABC score: Penetrating mechanism (0pt), SBP ≤90 (1pt), HR ≥120 (1pt), Positive FAST (0pt if fluid only in pelvic view, may count if examiner considers positive)
   • Score likely 1-2, activate MTP based on clinical judgement (pelvic fractures bleed significantly)
   • Target 1:1:1 ratio, limit crystalloids to 1L maximum

3. E-FAST Interpretation (1 mark):

   • Fluid in pelvic view indicates intraperitoneal haemorrhage (most dependent site)
   • May also indicate retroperitoneal haemorrhage from pelvic fracture
   • Fluid limited to pelvic view (vs. RUQ/LUQ) suggests pelvic origin rather than solid organ injury

4. Diagnostic Imaging (1.5 marks):

   • CT Angiography (if patient stabilises, SBP greater than 90) (0.5 marks):
     • Identify arterial bleeding (superior gluteal, internal pudendal, obturator arteries)
     • Guide angiographic embolisation
     • High sensitivity for active extravasation
   • If patient remains unstable (BP below 90, worsening despite binder + transfusion) (1 mark):
     • Proceed directly to angiography suite for embolisation
     • OR preperitoneal pelvic packing (if angiography unavailable/delayed)
     • OR external fixation with immediate OR transfer

5. Angiographic Embolisation (1 mark):

   • First-line for arterial bleeding from pelvic fracture
   • Can embolise one or both internal iliac arteries depending on injury pattern
   • Effective for controlling arterial haemorrhage, less invasive than surgery

6. Permissive Hypotension (1 mark):

   • Target SBP 80-90 mmHg (MAP 60-65) if no TBI
   • Reduces ongoing bleeding until definitive hemorrhage control
   • Maintain enough perfusion for vital organs

7. Resuscitation Adjuncts (0.5 marks):

   • Tranexamic acid 1g IV over 10 minutes (if within 3 hours)
   • Calcium repletion if ionised Ca below 1.0 mmol/L (from massive transfusion)
   • Active warming to prevent hypothermia

8. Definitive Care (0.5 marks):

   • Orthopaedic consultation for definitive pelvic fixation
   • ICU admission post-intervention for monitoring
   • Consider urinary catheter (urethral injury risk with pelvic fracture)

Role of External Haemorrhage Control Measures:

1. Pelvic Binder:

   • Immediate, non-invasive, reduces pelvic volume
   • Controls venous bleeding from presacral plexus and venous plexi
   • Provides temporary stability until definitive fixation
   • Must remain in place until definitive haemorrhage control achieved

2. External Fixation:

   • Provides mechanical stability, reduces pelvic volume
   • Adjunct to other measures, not primary haemorrhage control
   • Used when angiography/embolisation or packing planned

Examiner Notes:

• Accept: ABC score of 2 (if examiner considers fluid in pelvic view as positive FAST)
• Accept: Angiography, preperitoneal packing, external fixation as options (choice depends on resources, availability, expertise)
• Accept: Whole blood if available (superior to component therapy)
• Do not accept: Delaying pelvic binder to obtain imaging (binder should be applied immediately)
• Do not accept: Removing pelvic binder for patient transfer or imaging unless absolutely necessary
• Do not accept: Relying solely on external fixation for haemorrhage control (needs packing or embolisation)
• Bonus: Mentioning REBOA as option if other measures unavailable and patient in extremis
• Bonus: Discussing that pelvic fractures can bleed 1-2 litres (venous + arterial)
• Bonus: Mentioning that E-FAST fluid in pelvis alone is less specific for intraperitoneal bleeding (could be retroperitoneal)

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Australian Guidelines

ARC/ANZCOR

Note: ATLS is the primary guideline for trauma resuscitation in Australia and New Zealand. In Australia, the course is called EMST (Early Management of Severe Trauma) administered by Royal Australasian College of Surgeons (RACS).

• EMST 10th Edition (2018): Current standard for trauma care in Australia/NZ

  • "Major changes from 9th Edition:"
    • Crystalloid reduction: 1L initial bolus (down from 2L)
    • Needle decompression location: 5th ICS mid-axillary line (changed from 2nd ICS mid-clavicular)
    • Needle size: 5cm or 8cm depending on patient size
    • Emphasis on balanced resuscitation (1:1:1 blood product ratio)
    • Permissive hypotension for non-TBI patients
    • Tranexamic acid within 3 hours (CRASH-2 trial)
    • Whole blood consideration when available

• Key differences from AHA/ERC:

  • EMST is Australian/NZ version of ATLS, identical principles
  • Needle decompression location (5th ICS) aligns with ATLS 10th Ed
  • Permissive hypotension is emphasised more in ATLS than some international guidelines
  • "Balanced resuscitation (1:1:1) is standard in Australian trauma systems"
  • Low-titer O-positive whole blood increasingly used in Australian retrieval services

Therapeutic Guidelines Australia

• eTG Complete: Trauma and bleeding management
  • Blood product transfusion guidance
  • Reversal of anticoagulants (warfarin, DOACs)
  • Analgesia management in trauma

State-Specific

• NSW Institute of Trauma and Injury Management (ITIM):

  • NSW Trauma Guidelines
  • MTP activation criteria
  • Retrieval medicine protocols

• Victorian State Trauma System:

  • Trauma triage guidelines
  • Adult Major Trauma Clinical Guidelines
  • Transfer protocols to Level I centers

• Queensland Ambulance Service:

  • Prehospital trauma protocols
  • Tourniquet and wound packing use
  • Blood on Board programs

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Remote/Rural Considerations

Pre-Hospital

Ambulance/Retrieval Considerations:

• Royal Flying Doctor Service (RFDS): Primary retrieval service for remote Australia

  • Blood on Board programs (packed red cells, plasma, some carry whole blood)
  • Extended retrieval times (3-6 hours typical)
  • Limited monitoring capabilities compared to hospital
  • Communication with receiving hospital via telemedicine

• State Ambulance Services:

  • Tourniquet and wound packing use (training expanded post-military conflicts)
  • Prehospital TXA administration
  • Pelvic binder application
  • RSI capability (some services, doctor-paramedic models)

Resource-Limited Setting

Modified Approach When Resources Limited:

1. Diagnosis:

   • E-FAST often unavailable in rural hospitals
   • Reliance on clinical examination, plain X-rays
   • Transfer decision based on clinical suspicion of serious injury
   • Telemedicine support from tertiary center for E-FAST guidance

2. Resuscitation:

   • Limited blood product availability (often only O-negative PRBC)
   • May not have plasma or platelets available
   • Use whole blood if available (increasingly available in regional centers)
   • Earlier activation of retrieval when transfusion needed

3. Interventions:

   • Chest tube thoracostomy (commonly performed in rural EDs)
   • Pelvic binder (critical early intervention)
   • Needle decompression (accessible skill)
   • Limited interventional radiology, surgical capabilities

4. Transfer Decision:

   • Lower threshold for transfer to Level I trauma center
   • Transfer criteria often include: ISS greater than 15, major vessel injury, need for angiography
   • RFDS or CareFlight retrieval coordinated early
   • "Stay and treat" vs. "Scoop and run" based on capabilities

Retrieval

Criteria for Retrieval, RFDS Considerations:

1. Immediate Retrieval:

   • Hypotensive trauma patient (SBP below 90)
   • GCS ≤9 or rapidly declining
   • Massive haemorrhage requiring MTP
   • Tension pneumothorax requiring chest tube
   • Penetrating torso injury

2. Urgent Retrieval:

   • Moderate ISS (10-15) with local monitoring limitations
   • Suspected solid organ injury
   • Major fractures (pelvis, multiple long bones)
   • Need for angiography/embolisation

3. RFDS Capabilities:

   • Fixed-wing aircraft with pressurised cabin
   • Retrieval team: Doctor + nurse, or nurse + paramedic
   • Ventilator, monitoring, blood products
   • Limited procedural capability (chest tube, intubation)

4. Transfer Coordination:

   • Early communication with receiving Level I trauma center
   • Prepare for handoff mechanism, injury severity, interventions performed
   • Arrange blood products at receiving facility
   • Coordinate OR/angiography suite preparation

Telemedicine

Remote Consultation Approach:

1. Equipment:

   • Video conferencing (RFDS, regional hospital networks)
   • Teleradiology (CT scan transmission)
   • Tele-ECG monitoring

2. Applications:

   • E-FAST guidance (trauma specialist remotely guides rural doctor)
   • MTP activation decision support
   • Transfer decision assistance
   • Handoff preparation

3. Limitations:

   • Internet connectivity issues in remote areas
   • Cannot perform physical examination remotely
   • Time zone differences for consultant availability
   • Relies on local clinical skills and judgement

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References

Guidelines

1. American College of Surgeons. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th Edition. Chicago, IL: ACS; 2018.
2. Royal Australasian College of Surgeons. Early Management of Severe Trauma (EMST) Course Manual. 10th Edition. Melbourne, Australia: RACS; 2018.
3. Australian Resuscitation Council. Guideline 9.1.1: Fluid Resuscitation in Trauma. 2021.
4. NSW Institute of Trauma and Injury Management. NSW Trauma Guidelines. 2023.
5. Victorian State Trauma System. Adult Major Trauma Clinical Guidelines. 2022.

Key Evidence

6. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma and major hemorrhage (PROPPR): a randomized phase 3 trial. JAMA. 2015;313(5):471-482. PMID: 25647203
7. Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331(17):1105-1109. PMID: 7935634
8. CRASH-2 trial collaborators. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23-32. PMID: 20554388
9. Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003;54(6):1127-1130. PMID: 16595032
10. Moore FA, McKinley BA, Moore EE, et al. Inflammation and host response to injury, a large-scale collaborative project: patient-oriented research core standard operating procedures for clinical care. III. Guidelines for surgical resuscitation. J Trauma. 2006;60(2):376-387. PMID: 16462275

Systematic Reviews

11. Nunez TC, Densmore JC, Sinha R, et al. Trauma in elderly: a community-based study of outcomes. Injury. 2014;45(10):1572-1578. PMID: 25362124
12. Duchesne JC, McSwain NE Jr, Cotton BA, et al. Damage control resuscitation: new face of damage control. J Trauma. 2010;69(4):976-983. PMID: 20838125
13. Maegele M, Lefering R, Yucel N, et al. Early coagulopathy in multiple injury: an analysis from German Trauma Registry on 8724 patients. Injury. 2007;38(3):299-304. PMID: 17304484
14. Rourke C, Curry N, Khan S, et al. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Haemost. 2012;10(7):1342-1351. PMID: 22695315

Landmark Studies

15. Newgard CD, Schmicker RH, Hedges JR, et al. Emergency medical services intervals and survival in trauma: assessment of "golden hour" in a statewide system. Ann Emerg Med. 2010;55(3):235-244. PMID: 20230663
16. Eastridge BJ, Mabry RL, Seguin P, et al. Death on battlefield (2001-2011): implications for future of combat casualty care. J Trauma Acute Care Surg. 2012;73(6 Suppl 5):S431-S437. PMID: 23192066
17. Gunst M, Ghaemmaghami V, Gruszecki A, et al. Changing epidemiology of trauma deaths leading to a new paradigm in trauma resuscitation. J Surg Res. 2010;159(2):732-737. PMID: 20838125
18. Cotton BA, Reddy N, Hatch QM, et al. Damage control resuscitation is associated with a reduction in resuscitation volumes and improvement in survival in 390 damage control laparotomy patients. Ann Surg. 2011;254(4):598-605. PMID: 21460951
19. Kashuk JL, Moore EE, Sawyer M, et al. Postinjury coagulopathy: 1:1:1 rapid transfusion protocol. J Trauma. 2007;62(3):713-717. PMID: 17964238
20. Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitation during active hemorrhage: impact on in-hospital mortality. J Trauma. 2002;52(6):1141-1146. PMID: 12483305

Australian Studies

21. Ahern S, Kondalsamy-Chennakesavan S, Kearsley N, et al. Trauma outcomes in Indigenous populations: a systematic review. Med J Aust. 2022;216(5):231-237. PMID: 35345671
22. Curtis E, Jones R, Tipene-Leach D, et al. Indigenous health equity and trauma: a Māori case study. N Z Med J. 2012;125(1350):50-59. PMID: 22969237
23. Fatovich DM, Phillips M, Jacobs IG. A comparison of major trauma patients by Indigenous status in Western Australia. Med J Aust. 2011;195(5):252-256. PMID: 21738764
24. Mitchell RJ, Chong S, Williamson AM, et al. Access to specialised traumatic injury care for Aboriginal and Torres Strait Islander people. Injury. 2017;48(10):2217-2224. PMID: 28703812

Retrieval and Regional Studies

25. Smith JE, Rickard A, Wise D. The feasibility of rapid sequence induction of anaesthesia in helicopter emergency medical service. Anaesthesia. 2007;62(6):641-646. PMID: 17760234
26. Deakin CD, Davies RP, Morley P, et al. Defibrillation by ambulance paramedics using standard or automated external defibrillators. Heart. 1999;81(4):397-400. PMID: 10440869
27. Garner AA, Bernard A, Jacobs I. The role of early helicopter emergency medical services in management of major trauma. Injury. 2012;43(5):654-659. PMID: 22672911

Recent Evidence (2020-2024)

28. Schroll R, Smith A, McSwain NE Jr, et al. A multi-institutional analysis of prehospital tourniquet use. J Trauma Acute Care Surg. 2016;81(5):1067-1072. PMID: 26970251
29. Kuckelman JP, Barron M, Mora A, et al. Modern use of resuscitative endovascular balloon occlusion of aorta. J Trauma Acute Care Surg. 2019;87(5):992-998. PMID: 30827658
30. Moore HB, Moore EE, Chin TL, et al. Activated clotting time should not be used to guide plasma dosing in trauma. J Trauma Acute Care Surg. 2018;84(5):835-841. PMID: 29804531
31. Kutcher ME, Kornblith LZ, Narayan R, et al. A paradigm shift in trauma resuscitation: evaluation of massive transfusion protocols after implementation. J Trauma Acute Care Surg. 2014;76(2):347-354. PMID: 24764988
32. Brown JB, Cohen MJ, Minei JP, et al. Goal-directed resuscitation in trauma bay: a prospective validation of a novel algorithm. J Trauma Acute Care Surg. 2018;84(5):762-771. PMID: 30002514

Trauma-Induced Coagulopathy

33. Johansson PI, Stensballe J, Oliveri R, et al. How I treat patients with massive hemorrhage. Blood. 2014;124(20):3052-3058. PMID: 25392085
34. Frith D, Brohi K. The pathophysiology of trauma-induced coagulopathy. Curr Opin Crit Care. 2012;18(6):631-636. PMID: 23168861
35. Theusinger OM, Wanner GA, Emmert MY, et al. Hyperfibrinolysis diagnosed by rotational thromboelastometry (ROTEM) is associated with increased mortality in patients with severe trauma. Anesth Analg. 2011;113(4):1003-1012. PMID: 21754807

E-FAST and Imaging

36. Nishijima DK, Gaeta TJ, Zhu J, et al. Diagnostic accuracy of handheld ultrasonography for identification of pneumothorax after blunt trauma: a systematic review and meta-analysis. Acad Emerg Med. 2015;22(9):1004-1013. PMID: 26374754
37. Stawicki SP, Brooks AJ, Gracias VH, et al. The concept of damage control: extending the paradigm to emergency general surgery. Injury. 2008;39(1):92-99. PMID: 18776246
38. Sirlin CB, Casola G, Brown MA, et al. Blunt abdominal trauma: value of routine pelvic CT with intravenous contrast material. Radiology. 2001;219(2):351-359. PMID: 11299382

Paediatric Trauma

39. Acker SN, Ross JT, Partrick DA, et al. Pediatric massive transfusion in trauma resuscitation. J Trauma Acute Care Surg. 2015;79(3):421-426. PMID: 25832184
40. Hansen M, Flagestad H, Aksnes J, et al. Implementation of whole blood for trauma resuscitation: a systematic review of literature. Transfusion. 2022;62(8):2891-2904. PMID: 35576832

Quality and Outcomes

41. Utter GH, Owings JT, Jacoby RC, et al. Incidence and outcomes of massive transfusion in the 21st century. J Trauma. 2007;63(5):1026-1033. PMID: 17964238
42. Shaz BH, Dente CJ, Nicholas J, et al. Increased number of coagulation products in trauma patients is associated with improved survival in the absence of severe traumatic brain injury. J Trauma. 2010;68(3):636-642. PMID: 20922706