VAQ 1 Answer

VAQ 1 Answer

Background
We’ve decided to provide “worked” answers to these questions in a format that gives you an approach to the questions, outlining the key points that need emphasis and shows you how to dissect the question so that you don’t miss anything, and provide high level responses that will get you the best marks. (There will be some notes on the real case at the end).

The text IN BLUE are phrases that you can copy/write verbatim in your answer.

DESCRIBE (The Xray):
This is a barn-door, bloody obvious horrendous pelvic fracture. The 1st year medical student can tell you this.  What you need to emphasise in your answer is that you know the anatomy, the complications, the management options and the very, very high risk of death, and give consultant level description/interpretation.

Opening phrases like:
LIFE THREATENING PELVIC FRACTURE (yes, underlined, in all capitals)
Or:
Grossly radiologically/clinically unstable pelvic fracture/hip dislocation

…indicates to the examiners that you “get it”
Catch phrases like “open book” may also be used.

You still need to go on to provide a brief radiologic description of the fractures, but don’t get too bogged down. Use short, succinct phrases like:

Gross disruption of pelvic ring
Fractures of right & left ilium, ischium, pubic bones, +/- sacrum
Destruction of right acetabulum/penetration of right femoral head

The astute will notice that there is a pelvic binder in situ. – highlight this as it’s a crucial management step that’s already been done.

PELVIC BINDER IN SITU

(In case you can’t see it, it’s the white rectangle on the right, and the circular opacities below the left hip joint, they are joined by strings that cross over the front of the pelvis to pull it tight).

Relevant negatives:
Are there any in this case? His pelvis is wrecked…!!
Maybe mention: No IDC in situ – urethrogram before IDC

Part of your interpretation will also include recognizing complications, so you can add a final phrase like:

Ultra-High risk for:
Massive haemorrhage
Coagulopathy
Urologic injury
Solid organ injury
Diaphragmatic rupture
…etc etc (any other complications you can think of)
or you can leave this until the management section.

INTERPRET:
In this case this means management of the critically ill trauma patient. This is where you must analyze the clinical information, and tie it to the image.
Pelvic fractures are about CIRCULATION management, so concentrate on this.

Don’t forget the standard trauma question responses for Get Help/A/B/C/D/E, but make them specific to the case:

You could start with:
Activate:
Trauma team
Massive transfusion protocol
Notify
Orthopaedics
Blood bank
Theatre

A/B
Spinal Precautions
High flow O2

Consider co-existing chest injury/PTX/HTX/spinal injury
Intubate if:
GCS <8, Arrest

NB: Blindly saying you would RSI/intubate this patient may not  be the best approach.  If he’s still conscious, sedatives would wipe out the fickle BP that he has and may trigger cardiovascular collapse.  Tread warily, and if you are going to write: “Intubate”, make sure to mention that you appreciate the risk & how you will stop them arresting as the sedation/sux goes in.  But remember, this question is about CIRCULATION so don’t waste too much time on A & B.

Now onto the money: Circulation
Oddly in this scenario, there is bradycardia, hypotension, and bradypnoea…
What does this mean? It means that any second the patient is going to go into EMD/PEA and very soon after that asystole!!

I threw this curveball in as not recognising this and saying: “pulse normal” or “slightly bradycardic”, or getting sidetracked into talking about spinal shock would imply that you haven’t seen anyone brady-out and arrest as they bleed to death, (or haven’t seen spinal shock) and that if this was the examiners mum, you might not be the best person to manage the case…

So use phrases like: PRE-ARREST/IMMINENT ARREST to indicate that you recognize how serious this is.

What are the key principles of circulation management in this setting? (You wouldn’t necessarily use these subheadings in your answer, but you should mention the points listed).

Access:
Large bore/rapid infuser access x 2
Avoid femoral access
Fill the tank:
N.Saline 2-3L until blood available, use rapid infuser
Don’t overfill the tank:
Haemostatic/”damage control” resusc
Aim: SPB = 100, PR <100
Prevent further loss:

Maintain pelvic binder
Definitive haemorrhage control
Packing/Surgery vs Embolisation
Exclude/treat contributing injuries
External bleed/PTX/HTX – urgent CxR

Then you need to show that you know what the specific treatment options are for this condition & the complications, and they fall into some broad categories:

Bones
Maintain binder
Consider External fixation in the ED
Bleeding
Vessels:
Theatre vs Embolisation
Low Hb:
O-negative, Group Specific, X-Matched blood – as available
Coagulopathy
FFP, platelets, and TRANEXAMIC ACID (see below)
Avoid hypothermia

NB: The use of clotting factors and Tranexamic acid is still being optimized in the literature, so it’s not worth going into an esoteric discussion here, but mentioning it will show that you at least know the concepts.  The specifics are still very institution specific at this stage. See the excellent references below for some great information on these topics.

AND FINALLY, the “fluffy bunnies”. (Credit to Rachel Hoyle at Southern Health for that term)
These are the warm and fuzzy points that show that as the Consultant you are on top of all of the clinical and non-clinical aspects of the case.

Did you notice that the question said “unknown male”?  This means you need to delegate someone to find out who he is, and don’t forget your legal obligation to do Police bloods (if he’s stable enough!):

Contact Police re identification/family notification
Police blood alcohol

…would be a simple way to cover these point, and show that you are on top of EVERY aspect of the management.

SUMMARY
So there you have it, a difficult case, with a lot of information to get down in 7.5 minutes.  Remember to emphasise  (with capital letters/underlining) that you recognize the severity, use point form to get the information out succinctly, and don’t forget the finer points like mentioning the clotting factors, massive transfusion protocols etc.

The real case:
This was a real case that was called through by the ambos as “GCS 12, a bit tachycardic, but otherwise stable, likely pelvic fracture” 5 mins before arrival. When they arrived, the patient was GCS 3, and arrested as he hit the table.  We managed to get an output back and he made it to theatre, (after 2 lots of CPR & lots of blood products) and unfortunately he died the next day. The point is these patients can deteriorate in front of you to the point of death, and you need a fast, pelvic-fracture specific, systematic approach for this very high mortality condition,

References:

MASSIVE TRANSFUSION:
Patient Blood Management Guidelines Module 1: Critical Bleeding Massive Transfusion.
These are new, Australian, NH&MRC and Mulit-College endorsed guidelines on massive transfusion.  You must be au-fait with these guidelines.

Download here

TRANEXAMIC ACID:
CRASH-2 Trial
Click here to download the original CRASH-2 paper

Russell Gruen & Dev Mitra from Melbourne have written a fantastic 2-page critique of CRASH-2 and Tranexamic acid, if you read nothing else, read this.
Click here to download the Gruen/Mitra article

Wikipedia Page:
Sounds like it may have been written by the drug company as it doesn’t say anything bad about it, but worth a look for a quick synopsis on this “wonderdrug”:

PELVIC FRACTURE: (Thanks to Fred Mori at the Alfred for these)

Preperitonal Pelvic Packing for Hemodynamically Unstable Pelvic Fractures: A Paradigm Shift
Cothren, C Clay MD; Osborn, Patrick M. MD; Moore, Ernest E. MD; Morgan, Steven J. MD; Johnson, Jeffrey L. MD; Smith, Wade R. MD
Journal of Trauma-Injury Infection & Critical Care: April 2007 – Volume 62 – Issue 4 – pp 834-842

Institutional Practice Guidelines on Management of Pelvic Fracture-Related Hemodynamic Instability: Do They Make a Difference?
Balogh, Zsolt MD; Caldwell, Erica RN; Heetveld, Martin MD; D’Amours, Scott MD; Schlaphoff, Glen MBBCh; Harris, Ian MBBS; Sugrue, Michael MD
Journal of Trauma-Injury Infection & Critical Care: April 2005 – Volume 58 – Issue 4 – pp 778-782

Review of the pathophysiology and acute management of haemorrhage in pelvic fracture
George S.M. Dyer, Mark S. Vrahas, Injury, Int. J. Care Injured (2006) 37, 602—613

Extraperitoneal Pelvic Packing: A Salvage Procedure to Control Massive Traumatic Pelvic Hemorrhage
Tötterman, Anna MD; Madsen, Jan Erik MD, PhD; Skaga, Nils Oddvar MD; Røise, Olav MD, PhD
Journal of Trauma-Injury Infection & Critical Care: April 2007 – Volume 62 – Issue 4 – pp 843-852

No comments yet.

Leave a Reply