1. Trauma M Pearson

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

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

4. 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

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

6. 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

7. 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

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

9. 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

10. Modified RSI Classic RSI is dead!!! Modified RSI Titrate induction agent Bag with pPeak 10-12 Glidescope best

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

12. Lethal triad of trauma

13. 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

14. 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

15. Fluids: colloids Starches (Voluven) Stays ivi > 6 hours Replace blood loss 1:1 Interfere with coagulation Limit of 45-60 ml/kg/day Avoid in septic shock- impair kidney fx

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

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

18. Hypotensive resus UNTIL BLEEDING SURGICALLY CONTROLLED! Keep SBP 80-100 mmHg Keep MAP 60 mmHg ( ? Even lower?) Known HTS pt BP not >20% drop Give SMALL bolus crystalloids FAST!

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

20. Goal directed therapy Blood pressure: SBP 80, MAP 50-60Blood pressure: SBP 80, MAP 50-60 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 ?

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

22. 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!

24. Tranexamic acid CyclokapronAntifibrinolitic Stabilizes clot Give 1 g slowly ivi over 10-15 min, then infusion of 1g over 8 hours Reduce need for blood transfusion No increased thrombotic complications

25. 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

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

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

28. 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

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

30. Dynamic parameters SPVPPVSVV PASSIVE LEG RAISING

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

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

33. 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

34. 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

35. 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 91 1. Pre-op evaluation and pain mx 2.intra op management GA/ Spinal 3. Fluid mx 4.. ICU/ ward

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

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

38. Manage raised ICP Reduce CMRO2 Prevent convulsions Sedate patient Ventilate keep CO2 30-35 Let temp drift down to 36 degrees Prevent bucking against ETT