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Trauma Resuscitation

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Title: Trauma Resuscitation Author: Yael Moussadji Last modified by: Yael Moussadji Created Date: 7/17/2006 8:40:09 PM Document presentation format – PowerPoint PPT presentation

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Title: Trauma Resuscitation


1
Trauma Resuscitation
  • Yael Moussadji, R3
  • Emergency Medicine

2
resuscitare
  • Latin to reanimate or revive
  • Refers to the diagnostic and therapeutic
    maneuvers used to treat trauma patients
  • Defines restoration of physiologic parameters
  • Reversal of shock

3
Objectives
  • To review how to improve your efficiency in a
    trauma resuscitation
  • To review the pathophysiology of trauma and the
    keys to stabilizing your patient
  • To discuss (briefly) the controversies around
    fluid resuscitation
  • To discuss pre-hospital considerations and the
    trauma system at large

4
Epidemiololgy and the Trauma System
  • Trauma is a disease of the young and is the No. 1
    cause of death in people aged 1-37
  • Among fatal MVCs, 38 are associated with alcohol
    and drug use, and only 37 were wearing seatbets
  • Regionalization of trauma care first came about
    in the 1970s with the creation of the first
    trauma centre at the University of Maryland
  • Now regional planning with designated trauma
    centres is essential, and involves ambulance
    destination polices and quality assurance
    programs to monitor patient outcomes

5
Prehospital Considerations
  • The appropriate management of patients in the
    prehospital setting has been complicated by well
    intentioned traditional attempts to simplify it
  • The controversial issues most impact patients
    with post-traumatic internal hemorrhage and
    post-traumatic circulatory arrest

6
Tenants of Prehospital Trauma Care
  • Prevention of additional injury
  • Careful extrication, spinal immobilization,
    spliting
  • Rapid transport
  • Advance notification to trauma facility
  • Field interventions
  • Spinal immobilization, airway management,
    restoration of circulating volume

7
Post-traumatic hemorrhage
  • In 1994, a large prospective controlled clinical
    trial comparing immediate prehospital and ED
    fluid resuscitation with delayed resuscitation
    until arrival in the O.R. found that hypotensive
    patients with penetrating torso injuries did
    worse if they received early resuscitation with
    crystalloids (higher mortality, more post-op
    complications)
  • It is postulated that elevated SBP results in
    mechanical disruption of soft clot and dilution
    of clotting factors, accelerating ongoing
    hemorrhage
  • No studies have correlated fluid resuscitation
    with increased survival
  • Key factors in the survival of critically injured
    patients are limited to rapid transport to an
    appropriate facility and aggressive airway
    control

8
Guidelines for fluid administration
  • Despite the recent evidence, the American College
    of Surgeons recommendations for trauma
    resuscitation still maintain that an initial
    infusion of LR or NS is the standard of care for
    the initial treatment of hemorrhagic shock
  • It may be prudent however to undertake a moderate
    resuscitation for patients with uncontrolled
    vascular injuries of the torso (with the
    exception of the moribund patient)

9
Trauma-associated circulatory arrest
  • Implies that although the patient may be
    pulseless and apneic, the heart may still be
    beating (hypovolemia, tamponade, pneumo)
  • Survival is associated with younger age, single
    organ involvement, less than 10 min to surgical
    intervention, rapid prehospital ETI with slow
    (6-8 breaths/min) controlled ventilations
    (aggressive ventilation can severely impair
    cardiac output)
  • Scoop Treat vs Scoop Run

10
Conducting a Resuscitation
  • The trauma bay
  • Resuscitation physicians
  • Paradigms of resuscitation
  • Horizontal resuscitation one physician performs
    the primary and secondary surveys in their
    entirety
  • A second physician performs procedures as they
    come up

11
The Trauma Team
  • Success of a horizontal resuscitation depends on
    each member of the team understanding and
    executing her role while the identified team
    leader (YOU!) keeps control and makes treatment
    decisions
  • For all Level 1 traumas in our trauma system,
    EPs act as the assessment physician and conduct
    the initial primary /- secondary surveys stand
    to the patients right near the head and verbalize
    your findings loudly
  • If a procedure physician is available, he or she
    is positioned on the patients left and may need
    to perform chest thoracostomy, central line
    insertion, splinting etc
  • Trauma nurses are positioned on each side of the
    patient and are responsible for ECG monitoring,
    vital signs, labs, IV access and fluid
    administration

12
Hemorrhage and Shock
13
Goals
  • Securing the airway, maintaining ventilation,
    controlling hemorrhage and reversing shock
  • Trauma deaths show a trimodal distribution
    immediately, within the first 24 hours, in the
    next 3-4 weeks MOF is the leading cause of
    mortality in patients who survive the initial
    resuscitation and surgical intervention
  • Failure to adequately resuscitate in the ER can
    lead to acidosis, hypothermia, and coagulopathy,
    resulting in MOF and death
  • ISS, age, platelet count on admission, and
    lactate at 12 hours are all predictors of the
    development of MOF

14
Shock
  • Basic cellular derangement involves an imbalance
    of oxygen utilization
  • SIRS and MOF is on the far end of a continuum
    initated and perpetuated by inflammation and
    inflammatory mediators
  • Acute hemorrhage causes decreased CO and pulse
    pressure, resulting in tachycardia,
    vasoconstriction and redistribution of blood flow
    away from non-vital organs and initiating a
    multi-hormonal response
  • Aim is to stabilize and reverse these
    derangements before damage is done to individual
    organ systems
  • Base deficit is an indirect measure of lactate
    production and a reliable indicator of shock
    lactate correlates with depth of shock and is a
    predictor of mortality

15
Priorities in Management
  • Assess and manage the airway and ventilation
    simultaneously (ETI, CXR, thoracostomy)
  • Control external hemorrhage with manual pressure,
    obtain vascular access, and begin volume
    resuscitation with crystalloids /- blood
  • Identify source of hemorrhage ongoing blood loss
    causing hypotension can usually be found in the
    chest, abdomen, or retroperitoneum
  • Conduct of thorough exam with frequent
    reassessments of the ABCs incorporate the X-rays
    of the chest and pelvis and the FAST into your
    primary survey
  • Always protect the C-spine obtain X-rays once
    stable

16
Resuscitation Fluid
17
Colloid vs Crystalloid
  • A large evidence based review of more than 82
    studies comparing crystalloid to colloid
    resuscitation was published by the McMaster group
    in 1999 (Crit Care Med) there was no overall
    difference in mortality, pulmonary edema, or
    length of stay, but there was a trend toward
    better survival in trauma patients with
    crystalloid use (poor confidence intervals)
  • In order to show a significant difference in
    mortality, an RCT would have to enroll more then
    9000 patients
  • In a systematic review of 30 studies with 1419
    patients, albumin has been shown to increase risk
    of death
  • Overall the greatest difference is the
    exhorbitant cost of colloids compared to
    crystalloids
  • Therefore, colloid resuscitation cannot be
    recommended for routine use in the resuscitation
    of patients with hemorrhagic shock

18
NS or LR
  • The non-anion gap acidosis that has been noted
    with NS use is not secondary to hyperchloremia,
    but in fact a lactic acidosis secondary to
    hypoperfusion
  • LR improves this acidosis because the lactate
    isomer is converted to bicarb, which acts as a
    buffer
  • Adequate resuscitation returns the pH to normal
    regardless of which fluid is used
  • NS is preferred in patients with TBI because of
    the slight hypertonicity (154mmol/L)

19
Blood
  • The decision to transfuse is made after
    consideration of mechanism of injury, hemodynamic
    status, response to crystalloid infusion, and
    pre-morbid status
  • In general, all trauma patients should receive a
    2 L crystalloid infusion first
  • If they remain hemodynamically unstable or have
    had significant blood loss, begin transfusing
    immediately 2 units of O neg (O pos in men) wide
    open through a fluid warmer

20
Transfusion Triggers
  • One large multicentre RCT showed that receving
    transfusions to a Hg threshold of 90 conferred no
    physiologic benefit compared to 70, and in
    younger patients with less severe illness the
    mortality was higher (some benefit noted for
    patients with AMI and UA)
  • Patients with massive transfusions are at a
    higher risk of dying from their injuries
    independent predictors of mortality include
    persistent hypotension, inotrope requirements
    intra-operatively, and need for cross clamping of
    the aorta interestingly, the amount of units of
    blood transfused was not an independent predictor
    of a bad outcome
  • Therefore massive transfusion requirements cannot
    be used as an indicator to discontinue
    resuscitation efforts

21
Other Blood Products
  • During large volume transfusions of PRBCs, other
    blood products must be given
  • As a guideline, give 2 units FFP for every 4-6
    units of PRBCs (and when INR is elevated)
  • Platelet counts lt100 are common in severe trauma
    patients with ongoing bleeding should receive
    6-10 units of platelets

22
Approach to the Secondary Survey
  • Neurologic exam
  • LOC, pupils, H/N, CNs, TMs, spinal cord function,
    peripheral nerve exam
  • Ability to move extremities and sense pain
    indicates intact cord
  • Thoracic exam
  • Always remember to inspect and feel the chest
    wall for contusions, bony crepitus, flail
    segments, SC emphysema
  • Abdominal exam
  • Insertion of OG and foley, urine for RM
  • Cardiac exam
  • ECG
  • MSK exam
  • Identify deformity, swelling, tenderness check
    pulses

23
Diagnostic Imaging in Trauma
  • For the critically ill patient, incorporate
    X-rays of the chest and pelvis into your primary
    survey C-spine series early for the stable
    moderately injured patient
  • FAST can also be incorporated into the primary
    survey for the detection of hemoperitoneum and
    the identification of patients who need immediate
    laparotomy
  • Assesses heptorenal recess, splenorenal recess,
    and rectovesicular recess for free fluid false
    negative scans commonly involve bowel perfs,
    contained liver or spleen lacs
  • Also evaluates for pericardial fluid
  • Stable patients can be further assessed by CT,
    which is the gold standard in identifying
    location and extent of solid organ injury,
    presence of aortic or thoracic injury

24
Special Situations
25
Closed Head Injury
  • Hemorrhagic shock with CHI portends a poor
    prognosis persistent hypotension is one of the
    worst prognostic indicators for recovery
  • Treatment aimed at restoring BP, controlling
    bleeding, assuring adequate CPP
  • Diagnosis and treatment of hypotension always
    takes precedence over the head injury
  • Defer head CT in patients with evidence of
    intra-abdominal bleeding and hypotension they
    need a laparotomy
  • Do not withhold fluids for fear of cerebral
    edema consider HTS as a resuscitation fluid

26
Spinal Cord Injury
  • Neurologic shock and hemorrhagic shock can occur
    simultaneously treat first as presumed blood
    loss
  • Both are treated with aggressive fluid
    resuscitation
  • If bleeding has been excluded, vasopressors are
    indicated after adequate volume loading
  • Patients in neurogenic shock are inappropriately
    vasodilated and often bradycardic due to a loss
    of sympathetic tone
  • Dopamine is the drug of choice for its
    chronotropic, inotropic, and vasoconstrictive
    effects

27
The Elderly
  • Age alone is not a predictor or morbidity and
    mortality in trauma
  • However, elderly patients have less physiologic
    reserve, more premorbid conditions, and less
    ability to compensate for injury
  • Vascular compliance, myocardial reserve, and bone
    strength are compromised
  • Heart disease is the leading premorbid condition
    that puts elderly patients are higher risk of
    complications
  • Consider medications (beta-blockers, coumadin)

28
The Pediatric Patient
  • The majority of pediatric blunt trauma patients
    can be resuscitated and treated non-operatively
    with great success
  • All grades of liver, spleen, and kidney injuries
    can be managed non-operatively
  • Laparotomy has been shown to increase blood loss
    and transfusion requirements over successful
    non-operative management
  • Therefore children should be treated based on
    their response to resuscitation, not their injury

29
Conclusion
  • Preparation is key!
  • Own the room. Become comfortable and efficient as
    a team leader.
  • Rapid resuscitation and stabilization is where we
    can have the most impact on our patients
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