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Overview

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Title: Overview


1
Overview
  • To Provide a brief Knowledge of the different
    types of firearms and ammunition
  • To Present the type and extent of wounds that
    may be expected in UK Prehospital Care
  • Review the principle between permanent and
    temporary cavitation
  • To impart practical advice for the Prehospital
    practitioner in dealing with firearm injuries
    and provide some Pearls and Pitfalls

2
Prevelance
  • In 2009/10 there were 40 fatal injuries caused
    by the use of a firearm and 405 serious injuries.
    All of the 40 fatalities in 2009/10 involved a
    weapon being fired, with 28 of the fatalities
    involving the use of a handgun and 7 involving
    the use of a shotgun
  • Hand guns were fired in only 10 of offences but
    if they were fired 30 of these offences resulted
    in a fatal or serious injury, compared with 6
    for all other weapon types
  • Firearm offences involving any type of injury
    increased by 5 percent from 3615 in 2008/09 to
    3,641 in 2009/10
  • One police officer was seriously injured and a
    further 16 slightly injured by firearms whilst on
    duty in 2009/10. This is comparable with an
    average of 16 per year.
  • Homicides, Firearm Offences and Intimate Violence
    2009/10 Supplementary Volume 2 to Crime in
    England and Wales 2009/10

3
Firearms used by CO19. H K snipers rifle. MP5A.
Glock 19 Auto pistol.
4
Firearms used by naughty people.
  • Mac10
    Uzi

5
Naughty people guns cont Rifles
  • AK47

    Car 15 (Version of the
    M16)
  • Mikhail Kalashnikov

    Designed 1967
  • Avtomat Kalashnikova
  • Designed 1947

6
Ammunition
  • There are thousands of variants when it comes to
    bullets.

7
Some Physics.
  • Principia Matematica 1759 Sir Issac Newton E M x
    V
  • Willem Gravesande Émilie du Châtelet E
    M x V²
  • Kinetic Energy ½ M x V²
  • M16 bullet weighs 55gms but travels at 3200ft/sec
    .45 calibre bullet weighs 230gms but travels at
    810ft/sec. M16 bullet is roughly 1/5th the weight
    but produces FOUR times the energy. (1280ft/lb
    versus 335ft/lb) this is down to speed.

8
.32 Cal Subsonic
9
9mm Supersonic speed
10
HV 5.52cal Supersonic 2800ft/sec
11
  • Subsonic Supersonic
  • If the sum of the diameter of the entrance and
    exit wounds (if present) at their widest points
    is less than 10cm this is likely to be a low
    energy transfer wound. If the sum is greater than
    10cm or 2 fingers can easily be introduced into
    either wound the wound is likely to be high
    energy transfer.
  • Driscoll P, Skinner D, Earlam R.(2000) ABC of
    Major Trauma. 3ed Ed. London. Pg 152

12
Temporary Cavity
  • A High Energy round can produce 100x atmospheric
    pressure as it passes through tissue!! This
    gelatine block illustrates a HE round entering
    from the right and the temporary cavitation it
    causes.

13
Wound Profiles
  • Wound Profile a HE round (non-fragmenting)

14
Wound Profiles cont
  • Wound profile of a 9m.m round. Note how much more
    stable the round is

15
Wound Profiles Cont.
  • Wound Profile of a HE fragmenting round

16
Wound profiles Cont
  • Wound profile produced by a 7.62 full metal
    jacket bullet (from a AK-47) It does not deform
    in tissue and travels 26cm before it begins to
    yaw. This entrance wound can resemble a much
    lower velocity handgun wound.

17
Take Home Message
  • Treat the injury not the alleged weapon or
    ballistic characteristics. Use caution when
    describing wounds as exit or entrance

18

19

20

21
  • Abdominal visceral Injury occurs in 80-90 of
    bullet wounds but only 30 of stab wounds,
    however a ? of abdominal stab wounds with serious
    visceral injury at operation have minimal
    physical signs.
  • Driscoll P, Skinner D, Earlam R.(2000) ABC of
    Major Trauma. 3ed Ed. London. Pg 56

22
Take Home Message
  • Dont Assume Bullets Take Linear Pathways

23
Take Home Message
  • Some Bullet Wounds are not obvious!
  • Some look more superficial than they are!

24
Shotguns.
  • Shotgun cartridge just after leaving the barrel.
    At 2 meters. The dark object behind the
    Shot is

  • the wad.
    If fired from close range this can also

  • cause
    injury
  • Most serious human wounds occur within 18yards (
    17 meters) from the point of firing
  • DeMuth WEThe mechanism of gunshot wounds, J
    Trauma 11219,1971.

25
Shotguns
  • Explosive Gases will also damage tissue at close
    range

26
Shotgun Pellets are round and so will lose
speed and stability rapidly. Be prepared to
search more laterally for pellets
27
Patterns of Shotgun Injury
  • Type Wound appearance
    Injury Mortality
  • Contact
    Widespread tissue 85
    - 90
  • Close
    Penetrated beyond
    15 - 20

  • deep fascia
  • Intermediate
    Penetrates SQ tissue 0 -
    5

  • and deep fascia
  • Long Range
    Superficial skin
    0

  • penetration
  • Modified from Sherman RT, Parish RA Management
    of shotgun injuries a review of cases, J Trauma
    18236,1978

28
Take home message
  • Close range shotgun wounds are devastating.
    Assume major structural damage until proven
    otherwise. Look more laterally to impact point
    than normal.

29
On Approach
  • The 6 Ps
  • Prior Planning and Preparation Prevents Poor
    Performance.
  • Running Call
  • RVP RVP RVP RVP where are the police
    meeting???.., Duty Officer, Availability of
    HEMS/Air Ambulance/BASICS, Local Resus Capacity,
    Cardiothoracic/Neuro Capability? Special
    considerations CBRN/SORT

30
Safety at Scene
  • Appropriate PPE should
  • be used, when available, but
  • this does not mean that you
  • can then work in the inner
  • cordon. There is no role for the
  • NHS in the inner cordon.
  • She was saved from serious injury because
  • one shot was stopped by her stab-proof vest
  • and the other grazed her shoulder. Mrs
  • O'Rourke said she was attacked as she walked
  • back to her fast-response car after treating a
  • patient in King's Close, Leyton, at 3.30am on
  • 23 August 2009.

31
Behind Armour Blunt Trauma BABT
  • 1969 Vietnam 1st case report of lethal BABT US
    sergeant hit by M16 bullet died in 45 minutes
    due to massive pulmonary contusion.
  • Reported in 1970s by Caroll and Soderstrom case
    series of Police wearing kevlar soft armour hit
    by handgun bullets. All survived with no
    significant cardiorespiratory sequale.
  • 1995 Aid worker hit by 14.5mm bullet skin
    muscle damage Cx no ribs small haemothorax
    chestdrain. Later Cx in day showed developing
    pulmonary contusion uneventful recovery.
  • Largely assosiated with the defeat of low energy
    bullets and flexible textile armour systems.
  • UK police 5 threatgroups of armour
  • Maximum back-face deformation is 44 millimeters
    for low risk patrolling duties
  • Maximum back-face deformation is 25 millimeters
    for severe threat group
  • Keep in mind even if there is the absence of a
    defect on the skin
  • Mahoney PF, Ryan J, Brooks A, Schwab CW.(2005)
    Ballistic trauma A practical guide. 2nd Ed.

32
Treatment
  • Initial Assessment

33
ltCgt ABC
  • Catastrophic Haemorrhage
  • Battlefield Advanced Trauma Life Support (BATLS)
  • Inner-city gunshot wounds and increasingly
    prevalent knife injuries are likely to present
    civilian Prehospital and hospital personnel with
    casualties who may benefit from current military
    haemorrhage protocols or adaptations of these.
    The parallels illustrate the need for civilian
    medical, nursing and paramedical personnel to be
    aware of innovations and developments in the
    military environment, where change is accelerated
    by the military imperative to improve combat
    casualty outcomes , and to adopt practices, where
    appropriate, to the benefit of the NHS
  • T.J. Hodgetts, P.F. Mahoney. M.Q. Russell, M.
    Byers ABC to ltCgtABC redefining the military
    trauma paradigm. EMJ 200623745-746

34
Compressible V Non Compressible
  • Direct Pressure of the wound elevation of the
    limb
  • Wound packing
  • Windlass technique
  • Indirect Pressure
  • Use of tourniquet
  • Use of topical haemostatic agents at any time
  • The windlass technique involves application of a
    dressing directly over the wound, held in place
    by a broad bandage (or crepe bandage) secured
    with a not over the wound. A pen or a similar
    object is placed under the knot and rotated until
    tight and then secured in place, thus providing a
    sustained significant force of direct pressure.
  • C.Lee, K.M. Porter, T.J. Hodgetts. Tourniquet use
    in the civilian Prehospital setting. EMJ.
    200724584-587

35
Tourniquets Negatives
  • Majority of external haemorrhage can be
    controlled by direct pressure
  • Inappropriate use in a recent paper by
    Lakstein (2003) on military
  • tourniquet use, 47 of 110 tourniquet
    applications were not clinically
  • indicated.
  • Preventing arterial blood flow to a limb will
    result in ischemia. Continuous application for gt
    2hours can result in permanent nerve injury,
    muscle injury, vascular injury and skin necrosis.
  • Reperfusion injury may also result from
    tourniquet use.
  • Incorrectly applied in non amputated limbs there
    may be a mismatch between occlusion of the lower
    pressure venous outflow and inadequate occlusion
    of arterial blood flow. Therefore increasing
    distal bleeding.
  • Applied to a hypotensive patient pre
    resuscitation, haemorrhage may stop. However when
    resuscitated to a higher systolic the bleeding
    may restart.
  • A properly applied tourniquet is painful and this
    has led to inadequate tightening or inappropriate
    Prehospital removal.
  • In Laksteins study (2003) they identified that
    5.5 of 110 Prehospital tourniquet applications
    resulted in neurological complications, with an
    ischemic time between 109-187 minutes. None of
    these resulted in limb loss. The mean use of a
    tourniquet with no complications was 78 minutes.
  • C.Lee, K.M. Porter, T.J. Hodgetts. Tourniquet use
    in the civilian Prehospital setting. EMJ.
    200724584-587

36
Tourniquets why then?
  • Analysis of data from the Vietnam war found that
    7 of deaths potentially
  • avoidable.¹
  • US SF (2001-2004) in the Global War on Terrorism
    13 deaths potentially
  • avoidable.
  • Unpublished from this data 18 casualties from
    35 (51) who died from isolated extremity
    injury could have potentially been avoidable²
  • In a 4 year period of tourniquet use by the IDF
    Lankstein reported that there were no deaths
    from uncontrolled limb haemorrhage among 550
    injured patients.³
  • ¹Bellamy RF. The causes of death in conventional
    land warfare implications for combat casualty
    care research. Mil Med. 198414955-62
  • ² Holcomb JB, McMullin NR, Pearse L, et al.
    Causes of death in US Special Operations Forces
    in the global war on terrorism2001-2004. Ann
    Surg. 2007 245986-991
  • ³Lakstein D, Blumenfeld A, Sokolov T et al.
    Tourniquets for hemorrhage control on the
    battlefield a 4-year accumulated experience. J
    Trauma 2003 54 (5suppl)S221-S225)

37
Tourniquets Cont....
  • Recommended for stepwise approach or immediate
    application if
  • Extreme life threatening limb haemorrhage or
    limb amputation so that
  • A B can be treated and ltCgt then reassesed
  • Life threatening limb haemorrhage not controlled
    by simple methods
  • Point of significant haemorrhage from limb is not
    peripherally accessible due to entrapment
  • MCI with extremity haemorrhage and lack of
    resources to maintain simple methods of
    haemorrhage control.
  • If transit time to hospital is under 1 Hour the
    tourniquet should remain insitu until the patient
    is in the operating theatre
  • C.Lee, K.M. Porter, T.J. Hodgetts. Tourniquet use
    in the civilian Prehospital setting. EMJ.
    200724584-587
  • Write on tourniquet/PCR/forehead time of
    application. In a review of Operation Iraqi
    Freedom 39 of casualties who had prehospital
    tourniquets applied did not have time of
    application.
  • Beekley AC et al. Prehospital Tourniquet use in
    Operation Iraqi FreedomEffect on Hemorrhage
    control and outcomes. J Trauma 200864S28-S37

38
Haemostatic dressings/agents
  • Analysis of autopsy data from American casualties
    sustained in Iraq and Afghanistan has shown that
    over 80of casualties with potentially survivable
    wounds died from haemorrhage. Of these
    aproximatly 20 died from wounds in the neck,
    axilla and groin.
  • Kelly JF, Ritenour AE, McLaughlin DF et al.
    Injury severity and causes of death from
    Operation Iraqi Freedom and Operation Enduring
    Freedom 2003-2004 versus 2006.J Trauma.
    200864S21-S27

39
Physiology
  • The esssential end reactions of
    the clotting process
  • Prothrombin activator
  • Calcium ions (IV)
  • Prothrombin
    Thrombin
  • Fibrinogen (I)

    Fibrin
  • Action
    Transformation
  • Adapted from Hinchcliff S. et al 1999.
    Phyhsiology for nursing practise 2nd Ed

40
QuikClot
  • Works by absorbing the water component of blood
    in an exothermic reaction, thereby concentrating
    clotting factors, it also supplies Ca² ions and
    activates platlets as further adjuncts to
    coagulation.
  • A complex groin injury with transection of the
    femoral vessels and 3 minutes of uncontrolled
    hemorrhage was created in 30 swine. Mortality was
    83 without treatment, 33.4 with standard gauze
    and 0 with Quikclot.¹
  • Case review of 103 patients overall efficacy
    rate of 92, 3 cases of burns²
  • ¹Alam HB, Uy GB, Miller D et al. Comparative
    analysis of hemostatic agents in a swine
  • model of lethal groin injury . J Trauma. 200354
    1077-1082
  • ²Rhee P, Brown C, Martin M et al. QuickClot use
    in trauma for hemorrhage control case
  • series of 103 documented uses. J Trauma.
    2008641093-1099

41
Celox
  • Is a chitosan based dressing which has been noted
    to have an effect on haemostasis due to direct
    adherance to the wound, it may also aid in the
    recruitment of red blood cells and platelets,
    this process then forms a pseudo clot.
  • A complex groin injury with transection of the
    femoral vessels and 3 minutes of uncontrolled
    hemorrhage was created in 48 swine. The animals
    were then randomized to four treatment groups (12
    animals each).
  • Celox reduced rebleeding to 0 (p lt 0.001),
    HemCon to 33 (95 CI 19.7 to 46.3, p
    0.038), and QuickClot to 8 (95 CI 3.3 to
    15.7, p 0.001), compared to 83 (95 CI
    72.4 to 93.6) for SD. CX improved survival to
    100 compared to SD at 50 (95 CI 35.9 to
    64.2, p 0.018). Survival for HC (67) (95 CI
    53.7 to 80.3) and QC (92 95 CI 84.3 to
    99.7) did not differ from SD.
  • In use with DMS HEMS
  • Kozen BG, Kircher SJ, Henao J et al An
    alternative hemostatic dressing comparison of
    CELOX, HemCon, and QuikClot. Acad Emerg Med. 2008
    Jan15(1)74-81.

42
Prehospital Haemostatic dressings a
systematic review
  • From 60 articles collated, 6 clinical papers and
    37 preclinical animal trials were eligible for
    inclusion in this review. Products have been
    tested in three different types of haemorrhage
    model low pressure, high volume venous bleeding,
    high pressure arterial bleeding and mixed
    arterial-venous bleeding. The efficacy of
    products varies with the model adopted. Criteria
    for the 'ideal battlefield haemostatic dressing'
    have previously been defined by Pusateri, but no
    product has yet attained such status. Since 2004,
    HemCon (a mucoadhesive agent) and QuikClot (a
    factor concentrator) have been widely deployed by
    United States and United Kingdom Armed Forces
    retrospective clinical data supports their
    efficacy. However, in some recent animal models
    of lethal haemorrhage, WoundStat (mucoadhesive),
    Celox (mucoadhesive) and CombatGauze
    (procoagulant supplementor) have all outperformed
    both HemCon and QuikClot products.
  • Granville-Chapman J, Jacobs N, Midwinter MJ.
    Pre-hospital Haemostatic dressings A Systematic
    Review. Injury. 2010.Oct 27

43
Airway
  • OP
    Airway Manouvers
    NP
  • iGel

    LMA

  • ET

    RSI

44
C-Spine
  • 90 casualties sustained a penetrating neck
    injury. MOI explosion in 66 (73) and from GSW
    in 24 (27). Cervical spine injuries (either
    cervical spine fracture or cervical spinal cord
    injury) were present in 20 of the 90 (22)
    casualties, but only 6 of these (7) actually
    survived to reach hospital. Four of this six
    subsequently died from injuries within 72 h. Only
    1 (1.8) of the 56 survivors to reach a surgical
    facility sustained an unstable cervical spine
    injury that required surgical stabilisation. This
    patient later died as result of a co-existing
    head injury. Penetrating ballistic trauma to the
    neck is associated with a high mortality rate.
    Our data suggests that it is very unlikely that
    penetrating ballistic trauma to the neck will
    result in an unstable cervical spine in
    survivors. In a hazardous environment (e.g.
    shooting incidents or terrorist bombings), the
    risk/benefit ratio of mandatory spinal
    immobilisation is unfavourable and may place
    medical teams at prolonged risk. In addition
    cervical collars may hide potential
    life-threatening conditions.¹
  • In total, 45,284 penetrating trauma patients were
    studied 4.3 of whom underwent spine
    immobilization. Overall mortality was 8.1.
    Unadjusted mortality was twice as high in
    spine-immobilized patients (14.7 vs. 7.2, p lt
    0.001). The odds ratio of death for
    spine-immobilized patients was 2.06 (95 CI
    1.35-3.13) compared with nonimmobilized patients.
    Prehospital spine immobilization is associated
    with higher mortality in penetrating trauma and
    should not be routinely used in every patient
    with penetrating trauma.²
  • The current literature suggests that prehospital
    cervical immobilisation may not be necessary
    unless the patient has focal neurological
    deficits. ³
  • ¹HauteER, Kalish BT, Efron DT et al. Spine
    immobilization in penetrating trauma more harm
    than good? J Trauma. 2010 Jan68(1)115-20
  • ²Ramasamy A, Midwinter M, Mahoney P, Learning the
    lessons from conflict pre-hospital cervical
    spine stabilisation following ballistic neck
    trauma. Injury. 2009 Dec40(12)1342-5
  • ³Brywczynski JJ, Barrett TW, Lyon JA et al.
    Management of penetrating neck injury in the
    emergency department a structured literature
    review. Emerg Med J. 2008 Nov25(11)711-5

45
Breathing 100 O2
  • Feel Trachea
  • Look Wounds to neck
  • Auscultate Emphysema
  • Percuss Larynx
  • Veins
  • (Sa02) Expose

46
Breathing
  • Airway
  • Tension pneumothorax
  • Open pneumothorax
  • Massive haemothorax
  • Flail chest (pain releif)
  • Cardiac tamponade (20ml removal 25 aspiration
    not possible)
  • Driscoll P, Skinner D, Earlam R.(2000) ABC of
    Major Trauma. 3ed Ed. London. Pg21

47
Tension Pneumothorax
  • Universal findings
  • Chest Pain
  • Respiratory distress
  • Common findings (50-75)
  • Tachycardia
  • Ipsilateral decreased air entry
  • Inconsistent findings (lt 25 of cases)
  • Low SpO2
  • Tracheal deviation
  • Hypotension
  • Rare Findings (about 10)
  • Cyanosis, Ipsilateral chest hyper expansion or
    mobility
  • Hyperresonance, Sternal resonance /
  • Decreasing LOC , Acute epigastric pain / cardiac
    apical displacement
  • S Leigh-Smith, Harris T. Tension Pneumothorax
    time for a rethink?. Emerg Med J 2005228-16.

48
Needle Chest Decompression
  • Up to 40 failure rate in some studies Standard
    14g cannula not long enough for up to 35.4 of
    women and 19.3 men¹
  • Paramedic misdiagnosis (only 4/19) in one study²
  • 18 of 37 cases underwent chest decompression (17
    thoracostomy, 1 needle decompression). Four
    patients had a return of cardiac output (3
    tension pneumothorax, 1 bilateral pneumothorax).
    Six further cases were positive for intrathoracic
    injury. In 2 cases the injuries identified were
    incompatible with life and resuscitation efforts
    were consequently ceased³
  • ¹Mistry N, Bleetman A, Roberts KJ. Chest
    decompression during the resuscitation of
    patients in prehospital traumatic cardiac arrest.
    Emerg Med J. 2009 Oct26(10)738-40
  • ²S Leigh-Smith, Harris T. Tension Pneumothorax
    time for a rethink?. Emerg Med J 2005228-16.
  • ³Zengerink I, Brink PR, Laupland KB, Needle
    thoracostomy in the treatment of a tension
    pneumothorax in trauma patients what size
    needle? J Trauma. 2008 Jan64(1)111-4

49
Open Pneumothorax
  • The Bolin and Asherman chest seals were
    equivalent in preventing the development of a
    tension pneumothorax in this open pneumothorax
    model. However, the Bolin chest seal demonstrated
    stronger adherence in blood soiled conditions
  • Bolin

    Asherman
  • Arnaud F, Tomori T, Teranishi K, Evaluation of
    chest seal performance in a swine model
    comparison of Asherman vs. Bolin seal. Injury.
    2008 Sep39(9)1082-8

50
Circulation
  • Pulse Check Distal First/ Rate/ Rhythm
  • Skin temp/ appearance
  • Cap Refil
  • BP

51
Circulation Access
  • X 1 and if possible X2 14g IV Access in ACF but
    en route!!!
  • From October 1985 through November 1986 we
    prospectively studied IV access attempts in 350
    consecutive patients. Overall IV's started at the
    scene were 77 successful (n 70) and en route
    81 (n 213) of attempts were successful. Of
    those with BP less than 100 mm Hg, there were 66
    successful on-scene attempts and 72 successful
    en-route attempts. Protocols for IV
    administration in non-trapped patients should
    initiate IV access only en route to the hospital
    while the ambulance is moving. Even if delay at
    the scene is minimal, it is not possible to
    justify any delay, since IV's can be successfully
    instituted en route.
  • O'Gorman M, Trabulsy P, Pilcher DB. Zero-time
    prehospital i.v. J Trauma. 1989 Jan29(1)84-6

52
IO Access
  • EZ-IO Fast effective (97 effective
    function in combat casualties)
  • Simple technique
  • Expensive
  • Cooper BR, Mahoney PF, Hodgetts TJ, Intra-osseous
    access (EZ-IO) for resuscitation UK military
    combat experience.
  • J R Army Med Corps. 2007 Dec153(4)314-6

53
Fluids
  • A total of 776,734 patients were studied.
    Approximately half (49.3) received prehospital
    IV. Overall mortality was 4.6. Unadjusted
    mortality was significantly higher in patients
    receiving prehospital IV fluids (4.8 vs. 4.5, P
    lt 0.001). Multivariable analysis demonstrated
    that patients receiving IV fluids were
    significantly more likely to die (odds ratio OR
    1.11, 95 confidence interval CI 1.05-1.17).
    The association was identified in nearly all
    subsets of trauma patients. It is especially
    marked in patients with penetrating mechanism (OR
    1.25, 95 CI 1.08-1.45), hypotension (OR 1.44,
    95 CI 1.29-1.59), severe head injury (OR 1.34,
    95 CI 1.17-1.54), and patients undergoing
    immediate surgery (OR 1.35, 95 CI 1.22-1.50).
  • CONCLUSIONS The harm associated with prehospital
    IV fluid administration is significant for
    victims of trauma. The routine use of prehospital
    IV fluid administration for all trauma patients
    should be discouraged.
  • Haut ER, Kalish BT, Cotton BA et al. Prehospital
    Intravenous Fluid Administration is Associated
    With Higher Mortality in Trauma Patients A
    National Trauma Data Bank Analysis. Ann Surg.
    2010 Dec

54
Fluids
  • Crysrtalloids to be used
  • Penetrating injury boluses of 250mls to acheive
    verbal contact which is taken to indicate CNS
    perfusion adequacy.
  • In a patient where this endpoint is not possible
    SBP of 80mmhg is used
  • haemodynamically unstable code red to
    hopsital¹
  • Fluid rates 14g 1tr/3min, 16g 1tr/6min, 18g
    1tr/20min
  • Fluid at room temeperature will cause approx
    ?1ºC per Litre²
  • Fluids should be warmed to 39C prior to
    infusion³
  • ¹HEMS SOPs June 2008
  • ²BASICS monograph on Fluids
  • ³ PHTLS 6th ED

55
Coagulopathy
  • Is a defect in the body's mechanism for blood
    clotting, causing susceptibility to bleeding
  • The underlying mechanism ? anticoagulant Protein
    C pathway which ?factors V VIII
  • Up to 25 of trauma patients in some series have
    Acute Traumatic Coagulapathy, identified 20 min
    post injury and may be earlier
  • Hypothermia is a driver keep them warm
  • Haemodilution is a driver adhere to
    hypotensive resuscitation
  • Acidemia is a driver Oxygenate

56
CRASH 2
  • BACKGROUND Tranexamic acid can reduce bleeding
    in patients undergoing elective surgery. We
    assessed the effects of early administration of a
    short course of tranexamic acid on death,
    vascular occlusive events, and the receipt of
    blood transfusion in trauma patients.
  • METHODS This randomised controlled trial was
    undertaken in 274 hospitals in 40 countries. 20
    211 adult trauma patients with, or at risk of,
    significant bleeding were randomly assigned
    within 8 h of injury to either tranexamic acid
    (loading dose 1 g over 10 min then infusion of 1
    g over 8 h) or matching placebo. Randomisation
    was balanced by centre, with an allocation
    sequence based on a block size of eight,
    generated with a computer random number
    generator. Both participants and study staff
    (site investigators and trial coordinating centre
    staff) were masked to treatment allocation. The
    primary outcome was death in hospital within 4
    weeks of injury, and was described with the
    following categories bleeding, vascular
    occlusion (myocardial infarction, stroke and
    pulmonary embolism), multiorgan failure, head
    injury, and other. All analyses were by intention
    to treat. This study is registered as
    ISRCTN86750102, Clinicaltrials.govNCT00375258,
    and South African Clinical Trial
    RegisterDOH-27-0607-1919.
  • FINDINGS 10 096 patients were allocated to
    tranexamic acid and 10 115 to placebo, of whom 10
    060 and 10 067, respectively, were analysed.
    All-cause mortality was significantly reduced
    with tranexamic acid (1463 14.5 tranexamic
    acid group vs 1613 16.0 placebo group
    relative risk 0.91, 95 CI 0.85-0.97 p0.0035).
    The risk of death due to bleeding was
    significantly reduced (489 4.9 vs 574 5.7
    relative risk 0.85, 95 CI 0.76-0.96 p0.0077).
  • INTERPRETATION Tranexamic acid safely reduced
    the risk of death in bleeding trauma patients in
    this study. On the basis of these results,
    tranexamic acid should be considered for use in
    bleeding trauma patients.
  • Shakur H, Roberts I, Bautista R, 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 Jul 3376(9734)23-32

57
Diesel/ GLF
  • Time on Scene can Kill

  • (Also applies to in AE)
  • Outcome was worse in a group of 4856 patients
    brought to hospital by
  • Paramedics than in 926 patients brought in by
    bystanders, relatives
  • And police.
  • Demetriades D, Chan L, Cornwell E et al.
    Paramedic Vs Private transportation
  • of trauma patients. Effect on outcome. Arch Surg.
    1996 131133-8

58
Trauma Divert
  • Major trauma patients managed initialy in local
    hospitals have been shown to be 1.5 to 5 times
    more likly to die than patients transported
    directly to trauma centres
  • There is an average delay of 6 hours in
    transfering patients from a local hospital to a
    specialist centre. Delays of 12 or more hours are
    not uncommon. Across the UK, almost all ambulance
    bypasses can be acheived lt 30 mins
  • Lord Darzi 2008

59
Links
  • www.pafo.co.uk
  • www.tarn.ac.uk
  • www.advancedbleedingcare.org
  • www.fphc.info
  • www.ramcjournal.com
  • www.library.nhs.uk/athens
  • www.rcseng.ac.uk/service_delivery/trauma
  • www.nao.org.uk/idoc.ashx?docId2d37ade1-6e38-4b40-
    833e-38dab22f76f7version-1  PDF file

60
Going Slow
  • Hydrogen Sulfide Sprague-Dawley rats were
    subjected to controlled hemorrhage to remove 60
    of total blood. Hydrogen sulfide was administered
    to rats either via airway as gas, or intravenous
    infusion as liquid. Outcome was assayed by
    survival.
  • Results Using inhaled hydrogen sulfide gas, 75
    of treated and 23 of untreated rats survived
    longer than 24 hours. Using intravenous
    administered sulfide, 67 of treated and 14 of
    untreated rats survived longer than 24 hours.
    Morrison M, Blackwood J, Lockett S. Surviving
    Blood Loss Using Hydrogen Sulfide Journal of
    Trauma-Injury Infection Critical Care July
    2008, 65 1 183-188
  • Dr Hassan Boston Trauma Unit 10ºC hypothermic
    resucitation thorocotomy ice cooling ? 90
    survival
  • Cell death -reintro O2 Mitochondria is controller
    of death Profesor Beaker
  • Zenon gas (neuroprotective) neonates - TBI
  • Thromboelastrometry (TEM)

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