Trauma M Pearson

What is current? Low volume resus Intravascular fluids Tranexamic acid use Damage control surgery Modified RSI Mx bleeding and coagulopathy

Questions that remain Choice of fluid Target of hemodynamic goals Optimal prevention of coagulopathy Hypercoagubility

Hypovolemic shock Resus critical organs first Oxygen most important drug Isolated head injury not cause Progressive syndrome Recognise early and treat aggressively Confusion /agitation earliest symptom

Uncontrolled bleeding: First priority is to stop bleeding USE TOURNIQUET! Maintain oxygen delivery

Initial evaluation Still A- E Intubation with Etomidate or Ketamine Propofol X ( why?) Fluid bolus before induction agent RSI with Sux or Rocuronium 1,2 mg/ Avoid nasal intubation

Indications for immediate intubation Airway obstr unrelieved by basic manoeuvresAirway obstr unrelieved by basic manoeuvres Impending airway obstr ( facial burns/ inhalation injury)Impending airway obstr ( facial burns/ inhalation injury) GCS <9GCS <9 Haemorrhage from maxillofacial injuriesHaemorrhage from maxillofacial injuries Respiratory failure secondary to chest/ neurologic injuryRespiratory failure secondary to chest/ neurologic injury

Airway and C- spine Assume the presence of a spinal injury in any pt with head injury/ significant blunt trauma, until spine is cleared

Intubation in uncleared cervical spine Keep post collar on Head in neutral stand, no traction Manual in line stabilization Jaw thrust, no extension Bimanual cricoid pressure Adjunts Boogie, McCoy

Modified RSI Classic RSI is dead!!! Modified RSI Titrate induction agent Bag with pPeak Glidescope best

Secondary survey History AMPLE Undress pt and turn to evaluate back Avoid hypothermia Systematically from head to toe Remember PV and PR

Lethal triad of trauma

Fluids Principle: Don't pop the clot! Control bleeding as soon as possible! Tourniquet if necessary Prevent rather than replace blood loss NO IDEAL FLUID! "Abnormal" Saline only in TBI

Fluids : crystalloids Stays 30 min intravascular Interstitial oedema Dilutional coagulopathy 0,9% NaCl hyperchloremic metabolic acidosis Contribute to hypothermia Need large volumes to replace blood loss

Fluids: colloids Starches (Voluven) Stays ivi > 6 hours Replace blood loss 1:1 Interfere with coagulation Limit of ml/kg/day Avoid in septic shock- impair kidney fx

Fluids: Colloids Gelatins (Gelofusin) Bovine collagen Risk of allergic reactions Smaller molecules Stays ivi 3-4 hours

European guidelines Initial resus with crystalloids Add colloids in hemodynamic unstable pts

Hypotensive resus UNTIL BLEEDING SURGICALLY CONTROLLED! Keep SBP mmHg Keep MAP 60 mmHg ( ? Even lower?) Known HTS pt BP not >20% drop Give SMALL bolus crystalloids FAST!

CI to hypotensive resus Older patients Severe brain injury Longer transport times Pregnant patients Known ischaemic heart disease

Goal directed therapy Blood pressure: SBP 80, MAP 50-60Blood pressure: SBP 80, MAP Heart rate: < 120 beats/minHeart rate: < 120 beats/min Oxygenation: SpO2> 96%Oxygenation: SpO2> 96% Urine output: > 0,5 ml/kg/ hourUrine output: > 0,5 ml/kg/ hour Mentation: follow commandsMentation: follow commands Lactate level: < 1,6 mmol/lLactate level: < 1,6 mmol/l Base deficit: > -5Base deficit: > -5 Hemoglobin: > 9 g/ dl ?Hemoglobin: > 9 g/ dl ?

Use of Inotropes Use transiently to sustain BP and tissue perfusion during persistent hypotension despite fluid resuscitation Flow = P/R

Inotropes Flow= P1-P2/R BP not indication of perfusion! PEP alpha1 agonist with peripheral vasoconstriction Adrenalin 0,04-0,8 mcg/kg/min Dobutamine is vasodilator, can drop BP!

Tranexamic acid CyclokapronAntifibrinolitic Stabilizes clot Give 1 g slowly ivi over min, then infusion of 1g over 8 hours Reduce need for blood transfusion No increased thrombotic complications

Blood transfusions No specific transfusion trigger Individualize per pt and procedure Replace with packed RBC: FFP 1,5:1 FFP 10 ml/kg Platelet transfusion if platelets < 50

Anaesthesia Prepare theatre bair hugger Prepare for difficult airway Ivacs and inotropes Blood warmer and line Re-examine pt ( GCS, abdomen Repeat Hb

Anaesthesia Modified RSI avoid Propofol Lung protective ventilation Avoid N2O Check airway pressures for pneumothorax

Anaesthesia Ketamine/ etomidate induction Correct hypovolemia before induction Ketamine/ N2O paradoxal depressant effects Small doses Ketamine 25mg every 15 min usually well tolerated MAC vapours potentiated in shock. Use MAC 0,5-0,6

Hemodynamic monitoring Clinical parameters BP= ( HR x SV) x SVR Static parameters Limitations of CVPs Dynamic parameters best!

Dynamic parameters SPVPPVSVV PASSIVE LEG RAISING

Damage control surgery Unstable pt Control bleeding Control source of sepsis X -fix fractures Bogota bag abd compartment syndrome

Criteria extubation GCS > 8 Bleeding controlled Hb >7 Temp > 36 Maintain sat on FiO2 40% BP not inotrope dependent

Pain control Morphine 0,1 mg/kg ivi No ceiling on dose! Titrate against BP, RR and pain Ketamine 0,25-0,5 mg ivi Avoid NSAIDSs Perfalgan Nerve plexux block with LA ideal

Trauma in pregnant patient Remember left lateral tilt! Do sterile speculum for PV bleeding Fetal monitoring UWD diaphragm is higher Do sonar for abruptio Placenta bloodflow dependant on MAP

Trauma case scenario 28 yr old male involved in motorcycle accident. Booked for intramedullar nail femur# and xfix open tib-fib # GCS 13 BP 90/56 HR 132 RR 28 Sat Pre-op evaluation and pain mx 2.intra op management GA/ Spinal 3. Fluid mx 4.. ICU/ ward

Head injury and raised ICP Reduce raised ICP Maintain CPP A single episode of hypoxia/ hypotension is devastating!

Manage raised ICP Improve venous drainage Elevate head of bed Head neutral position ETT tie Ventilation pressures < 35 cmH2O

Manage raised ICP Reduce CMRO2 Prevent convulsions Sedate patient Ventilate keep CO Let temp drift down to 36 degrees Prevent bucking against ETT