--- module: 044-01 language: en chapter: 44 title: "Trauma, Resuscitation, Altered Consciousness, and Perioperative Assessment" module_title: "Foundations" source_sha256: 40864e6ed1d22a48ef86d84f291d25140ba0eb71b5b38cd723c4f2df086d73fd --- # Trauma, resuscitation, consciousness, perioperative care ## Orientation and primary survey ### Reversible threats before diagnosis #### Trajectory outweighs one normal observation ### Prepare team, warming, blood, airway, imaging ### Sequence: haemorrhage, airway, breathing, circulation ### Treat each threat when found, reassess after each step ### Haemorrhage control matched to site #### Tourniquet proximal, tightened, time documented ## Airway and cervical spine ### Look for blood, burns, stridor, expanding haematoma ### Jaw thrust, suction, oxygen, suitable adjuncts ### Definitive airway when protection or course unsecured ### Rapid-sequence intubation can cause arrest #### Hypovolaemia, right-heart obstruction, acidosis #### Resuscitate first, failed-airway plan #### Confirm with waveform carbon dioxide ### Spinal restriction must not delay airway or bleeding ## Breathing and chest injury ### Tension pneumothorax treated before imaging ### Massive haemothorax: blood loss, lung compression ### Flail segment and contusion #### Pain, impaired ventilation, delayed hypoxaemia #### Analgesia, physiotherapy, selective support ### Tamponade causes obstructive shock ## Circulation and haemorrhagic shock ### Haemorrhagic until proved otherwise ### Early signs precede hypotension #### Young patients maintain pressure until late ### Warmed blood components, not excess crystalloid #### Crystalloid dilutes clotting, cools, acidifies ### Early tranexamic acid within evidence window ### Damage-control resuscitation #### Permissive hypotension until haemostasis #### Inappropriate in severe traumatic brain injury ### Lethal triad is self-reinforcing #### Warm, control bleeding, shorten procedures ## Disability and altered consciousness ### Consciousness, pupils, limbs, glucose, temperature ### Coma scale: record components, not score alone ### Many causes: trauma, hypoxia, glucose, toxins ### Empirical glucose, naloxone, anticonvulsant #### Must not delay ventilation or imaging ### Prevent secondary brain injury #### Avoid hypoxia, hypotension, fever, glucose extremes ### Herniation signs demand urgent action #### Hyperosmolar therapy, imaging, neurosurgery ## Exposure, secondary survey, imaging ### Expose back, perineum, axillae, scalp, skin ### Head-to-toe examination after immediate threats #### Repeat: pain, distraction, shock conceal findings ### Focused ultrasound cannot exclude all injury ### Tomography only when stable or stabilised ### Pregnancy does not justify withholding diagnosis ## Specific injury patterns ### Traumatic brain injury types #### Anticoagulation raises risk, may need reversal ### Spinal-cord injury by level #### Neurogenic shock: lost sympathetic tone #### Relative bradycardia, after haemorrhage excluded ### Abdominal injury without early peritonism ### Pelvic binder over the greater trochanters ### Limb threat: artery, compartment, open, crush #### Neurovascular status before and after ## Cardiac arrest and post-resuscitation ### Compressions, defibrillator, minimal interruption ### Non-shockable: adrenaline, reversible causes ### Airway must not degrade compressions #### Waveform carbon dioxide: tube, quality, return ### After return of circulation #### Oxygen without prolonged hyperoxia #### Delay prognosis until confounders addressed ## Preoperative assessment, medicines, fasting ### Risk modification, not clearance ### Define urgency, magnitude, blood loss, destination ### Tests only when they change management #### Normal test does not offset poor function ### Explicit plans for each medicine #### Balance bleeding against thrombosis #### Glucocorticoid cover for adrenal suppression ### Fasting reduces aspiration, excess dehydrates ### Withhold sodium-glucose cotransporter inhibitors #### Euglycaemic ketoacidosis risk ## Postoperative physiology and complications ### Surgery and anaesthesia alter every organ ### Monitor airway to surgical site ### New deterioration is not expected change ### Prevention: analgesia, lung expansion, mobilisation ### Differential by timing and phenotype