Trauma resuscitation a review Prepared by Shane Barclay MD

Overview Definition of Trauma The 3 groups of mortality The ‘deadly triad’ The ‘golden hour’ The concept of permissive hypotension Goals of resuscitation Steps in Trauma Resuscitation

Definition of trauma The most common definition of major trauma is ‘major injury affecting more than one body system’. There is also a Injury Severity Score >15.

Mortality in trauma Trauma is the leading cause of death under age 40. Most commonly are males.

The Golden hour This was a concept within ATLS/Trauma Resuscitation that emphasized that to reduce mortality it was critical to manage trauma within that first hour. Realistically, in a rural setting, often it takes well over an hour for patients to be extricated and transported to the nearest hospital. In addition, several studies have shown no increased mortality when EHS spends ‘time in the field’ managing patients.

The ‘Golden hour’ Trauma mortality studies have consistently demonstrated that survival is related to whether or not the patient is transferred to a tertiary trauma center. Fortunately most trauma patients in BC are transported to urban tertiary centers.

Mortality in trauma Death from major trauma occurs in three groups: Immediate – ie at the scene. Often due to fatal injuries to the head, heart and great vessels. Early – occurs in minutes to hours. Often due to hemorrhage, respiratory and cardiovascular collapse. Late – occurs days to weeks later, often due to sepsis and multi organ failure.

Initial Goal From a hospital standpoint, we deal with the second group of patients, ie have not died at the scene but can die in your emergency room. Trauma Resuscitation/ATLS is designed to manage this ‘second’ group of patients in the hope of preventing death in the ER but also later on in the ICU

Initial Goal Although ATLS teaches a step wise manner, really the initial goal of all this is to 1. Maintain circulating volume 2. Control/stop hemorrhage 3. Correct or prevent the ‘lethal triad’ of - Coagulopathy - Acidosis - Hypothermia

Initial Goal Maintain circulating volume – “permissive hypotension” - This is a long standing concept with much written about it. - Bottom line is there is no advantage to having a patient’s MAP > 65. - Excessive crystalloid is associated with increased hypothermia, coagulopathy and death. - If you think your patient is bleeding (out) don’t even consider crystalloids, give blood!

Initial Goal Maintain circulating volume – “permissive hypotension” - exception to permissive hypotension is head and spinal injury, as these patients likely need a MAP > 80 to maintain cerebral perfusion. Summary: If no head trauma MAP < 65 give blood or fluids MAP > 65 if peripheral perfusion seems inadequate, can try some IV narcotic and that can often drop the BP, then give blood produts.

Initial Goal 2. Control/Stop hemorrhage. This would seem intuitive, however often the bleeding is occult or internal making management difficult. - Remember to use Tranexamic Acid. - ideally EARLY in trauma resuscitation (within 3 hrs) - Give 1 gm bolus then 1 gm over 8 hours.

Initial Goal 3. Prevent the lethal triad: - coagulopathy, hypothermia and acidosis.

Initial Goal Coagulopathies. - 25% of trauma patients bleed abnormally. - This has been called Acute Coagulopathy of Trauma Shock (and other names) - Is different than DIC - Hypothermia (cool crystalloids) and Acidosis (inadequate oxygen carrying capacity) both contribute to this coagulopathy. ie Give Blood

Initial Goal Coagulopathies. From a rural perspective, most rural hospitals do not have platelets, fresh frozen plasma and in fact often limited packed red cells (ie a few bags of O neg), so treating coagulopathy is more theoretical.

Initial Goal Predictors of outcome? One predictor that can help you see ‘how you are doing’ is a patient’s INR. Why? Brain injury and hemorrhage both cause release of factors that ‘use up’ factor seven and therefore raise INR. A second predictor is Lactate. A third predictor is urine output. (good if producing > 50 cc/hr)

First steps So.. other than becoming sweaty and tachycardic, what should you do as the team leader in a trauma code?

First steps The 3 most important steps are: Designate clear roles. Ensure effective communication. Start transfer services early.

First steps 1. Designate team members. 2. Call in lab, x-ray. 3. Consider ‘Code Blue’ ie get as much help as you can. 4. Get as much equipment ready as possible – RSI equipment, Ventilator, IV bags with pressure, etc If you are in a small rural hospital with limited staff, this is where you as a doctor, knowing all your equipment location, how to operate etc (ie ‘Owning the ER’) becomes so critical.

ABCDE

A B C D E Airway with C-Spine Control Breathing Circulation. Look, Listen & Feel for breath sounds. Suction if necessary Chin lift, jaw thrust, oral airway Problem? Consider Intubation Breathing Listen to chest, look for JVD, Trachea midline? Problem? Consider need for chest tube/pericardiocentesis? Circulation. BP, skin color, capillary refill Look for obvious bleeding, apply pressure Start 2 IV’s (Ringers), blood for CBC, lytes, Blood type/x-match Disability. AVPU: (Alert, Verbal Response, Pain Response, Unconscious) Glasgow Coma Scale Expose and Environment Remove ALL clothing, cover with warm blanket Log Roll (protecting spine) and inspect back. Temperature

Secondary Survey – “Head to Toe” Trauma Resuscitation Secondary Survey – “Head to Toe” Light in ears, eyes, mouth Palpate scalp, facial bones, +/- C-spine and collar bones. If OK, insert NG tube. (If patient is going to be intubated, wait, insert OG after) Listen to heart - ? Muffled Listen to chest, look at neck for JVD and tracheal deviation. Palpate abdomen. Palpate pelvic bones (down, out and distract legs). Rectal exam (if not done on log roll) - any blood at meatus? If normal, insert Foley – do urine preg test on females. Palpate arms for pain, have patient move feet, bend knees, assess foot planar/dorsi flexion, assess sensation and reflexes, plantar responses.

Trauma Resuscitation eFAST Substernal for PCE Abdomen for free fluid – check lungs for hemothorax Pelvis for free fluid Pleura for pneumothorax

Radiology “Trauma Series” CXR Pelvis C-Spine Trauma Resuscitation Radiology “Trauma Series” CXR Pelvis C-Spine

Trauma Resuscitation “AMPLE History” Allergies Medications, Drugs/Alcohol Ingestion Past Medical/Surgical history Last meal, LMP/Pregnant Events: History of accident and mechanism.

Trauma Resuscitation Positioning the patient: Trauma or shock patients should ideally be resuscitated with the head up 30-45 degrees to prevent aspiration. If spinal precautions prevent this, then you can put the whole stretcher in reverse Trendelenburg.

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