Sun28November0333PM 32

A 19-year-old male is admitted to the Emergency department with a crush injury of the pelvis.

Clinical examination is as follows:

Airway:

Patent

Breathing:

Respiratory rate 25 breaths per minute

Breath sounds vesicular, nil added

Circulation:

Capillary refill time of 4 seconds

Cool peripheries

Pulse 125 beats per minute

Blood pressure 125/96 mmHg

Disability:

Glasgow coma score 15

Anxious and in pain.

Secondary survey does not reveal any other significant injuries. The patient is given high flow oxygen therapy and intravenous access is established.

Which one of the following options is the most appropriate initial route of intravenous access?

(Please select 1 option)

Cut-down right saphenous vein

Intra-osseous needle left tibia

Right internal jugular vein

Left subclavian vein

Left cephalic vein Correct

Explanation

The clinical signs suggest that 15-30% of circulating blood volume has been lost.

Pelvic fractures are associated with significant concealed haemorrhage (>2000 ml) and may require aggressive fluid resuscitation. Other priorities include stabilisation of the fracture(s) and pain relief.

The Advanced Trauma Life Support (ATLS) classification of haemorrhagic shock is as follows:

Class I haemorrhage (blood loss up to 15%):

<750 ml of blood loss

Minimal tachycardia

No changes in blood pressure, RR or pulse pressure

Normally not require fluid replacement as will be restored in 24 hours, but in trauma correct.

Class II haemorrhage (15-30% blood volume loss):

Uncomplicated haemorrhage requiring crystalloid resuscitation

Represents about 750 - 1500 ml of blood loss

Tachycardia, tachypnoea and a decrease in pulse pressure (due to a rise in diastolic component due action of catecholamines)

Minimal systolic pressure changes

Anxiety, fright or hostility

Can usually be stabilised by crystalloid, but may later require a blood transfusion.

Class III haemorrhage (30-40% blood volume loss):

Complicated haemorrhagic state in which at least crystalloid and probably blood replacement are required

Classical signs of inadequate perfusion, marked tachycardia, tachypnoea, significant changes in mental state and measurable fall in systolic pressure

Almost always require blood transfusion, but decision based on patient initial response to fluid resuscitation.

Class IV haemorrhage (> 40% blood volume loss):

Preterminal event patient will die in minutes

Marked tachycardia, significant depression in systolic pressure and very narrow pulse pressure (or unobtainable diastolic pressure)

Mental state is markedly depressed

Skin cold and pale

Need rapid transfusion and immediate surgical intervention.

Loss of >50% results in loss of consciousness, pulse and blood pressure.

The route of choice is an arm vein (cephalic) with one or two large bore cannulae. This will enable initial aggressive fluid resuscitation. A central line can be inserted at a later stage if central venous monitoring is deemed necessary. If a suitable peripheral vein cannot be cannulated with a large bore cannula then the internal jugular vein could be accessed rapidly (preferably ultrasound guided).

Intravenous access below the diaphragm in this case is inadvisable when other routes are available.

Answer Statistics

1

1%

2

4%

3

17%

4

4%

5

76%

Times answered: 282