Transcript Trauma Resuscitation - Vanderbilt University Medical Center

Trauma Resuscitation
Shelley Atkinson RN, MSN, ANP-BC, ACNP- BC
Objectives
• Identify the correct sequence of priorities for
assessment of a multiple injury trauma
patient.
• Identify the principles outlined in the primary
and secondary evaluation surveys to the
assessment of a multiple injury patient.
• Identify guidelines and techniques in the
initial resuscitative and definitive-care phases
of treatment of a multiple injury patient.
Injury Statistics
• Leading cause of death for ages 1-44
• $ 500 billion dollar annual cost
• Estimated 20-50 million injuries occur per year
(40 % of emergency room visits)
• Leading causes of trauma are motor vehicle
crashes, falls, and assaults
Trimodal Death Distribution
• Death due to injury
occurs in one of
three periods or
peaks
• Care provided
during each of
these periods
impacts patient
outcomes
Trimodal Death Distribution
• First peak – occurs within seconds to minutes
of injury
• Second peak – occurs within minutes to
several hours following injury
• Third peak – occurs several days to weeks
after initial injury
Advanced Trauma Life Support (ATLS)
Assess the patient’s condition rapidly and
accurately
Resuscitate and stabilize the patient according
priority
Determine if patient’s needs exceed a facility’s
resources/or doctor’s capabilities
Arrange for transfer (what, where, when, who,
and how)
ATLS
• Assure that optimum care is provided and
level of care does not deteriorate at any point
during evaluation, resuscitation, or transfer
process
What is a Level One Trauma Center?
A hospital equipped to provide
comprehensive emergency medical services to
patients suffering traumatic injuries.
Level One Criteria
Airway/Breathing
• Unstable airway/unsecure airway
• Patients with severe maxillofacial injuries
• Patients requiring immediate airway
intervention
• Facial burns / suspected inhalation injury
• Moderate to severe Respiratory distress
• Sub Q air in face, neck, or chest
Level One Criteria
Circulation
• Systolic BP < 90mmHg or HR > 120
• Witnessed cardiac arrest from trauma
• Uncontrolled/Arterial Bleeding with shock
• Spinal/Neurogenic Shock
Level One Criteria
CNS
• GCS ≤ 8
• Head injury with LOC > 5 min
• Known spinal cord injury
• Neurologic deficits with suspected spinal cord
injury (any level)
Level One Criteria
Chest/Abdomen/Pelvis
• Chest/Abdominal/Pelvic Injury with shock
• Chest wall injury
– Flail chest
– Sucking chest wound
– Subcutaneous air
• Pregnancy ≥ 24 weeks with significant
mechanism of injury
Level One Criteria
Extremities
• Multiple long bone fractures with shock
• Mangled Extremity or Amputation
– above wrist/ankle
Level One Criteria
Mechanism of Injury
• Penetrating trauma to the head, face, torso
(chest, abdomen, buttocks, back)
• Ejection from vehicle
• Fall from 20 or more feet with presence of
other Level I criteria
• Electrocution/Electrical Injury with entry/exit
wounds
Level One Criteria
Mechanism of Injury
• Burns > 20% TBSA or burns combined with any
other injury
• Massive crush injury
Pre-hospital care
Initial Assessment
Primary survey and
resuscitation of vital
functions are done
simultaneously.
A team approach
Primary Survey
ABCDEs
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•
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Airway with cervical spine protection
Breathing
Circulation with hemorrhage control
Disability: Neurologic status
Exposure/Environment
What is the number one priority
during the initial assessment of a
trauma patient?
A. Airway
B. Airway
C. Airway
D. All of the above
Airway Obstruction Recognition
Look
Listen
•
•
•
•
•
• Normal speech- no
obstruction
• Noisy breathing –
obstruction
• Gurgle
• Stridor
• Hoarseness
Agitation/Obtunded
Decreased air movement
Retraction
Deformity
Airway debris
Inadequate Breathing
Look
Listen
• Cyanosis
• “I can’t breathe”
• Change in Mental Status
• “I am dying”
• Chest asymmetry
• Stridor, wheezes
• Tachypnea
• Decreased or absent breath
sounds
• Neck vein distention
• Paralysis
Feel
• Sub Q emphysema/chest wall crepitus
• Tracheal deviation
Which way for the Airway?
Rapid Sequence Intubation
• Be prepared to perform a surgical airway in
the event that airway control is lost
• Pre-oxygenate patient with 100% oxygen
• Administer analgesic / sedative (IV) if feasible
• Apply pressure over cricoid cartilage
– Debatable
• Administer a paralytic IV
• Perform chin lift/jaw thrust
Rapid Sequence Intubation
• After the patient relaxes, intubate
orotracheally
• Inflate cuff and confirm placement
– auscultate and determine CO2 in exhaled air
• Release cricoid pressure
• Ventilate
• CXR
Adjuncts to Primary Survey
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•
•
•
ECG
CO2 detector
Pulse oximetry
Vital Signs
Primary Survey
Circulation with Hemorrhage Control
• Control hemorrhage
• Activate trauma (Massive Transfusion Protocol)
– 6U pRBC, 4U FFP, 1 Platelets
– MD activation only
• Judicious use of crystalloid
6 areas potential blood loss
•
•
•
•
•
•
•
Chest
Abdomen
Retroperitoneum
Pelvis
Long bones / Soft tissue
Scalp
…the ground
Trauma
• Majority deaths occur in 1st few hours after
injury
• Hemorrhage largest % deaths within 1st hour
• Hemorrhagic shock and exsanguination
– 80% deaths in OR
– 50% deaths 1st 24 hrs after injury
• Very few hemorrhage deaths after 1st 24 hours
• Only CNS injury more lethal
Special Considerations In Diagnosis
and Treatment of Shock
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•
•
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Age
Athletes
Pregnancy
Medications
Hypothermia
Pacemakers
Vascular Access
• 2 large-caliber, peripheral IVs
• Central access
– femoral
– jugular
– subclavian
• Intraosseous
• Obtain blood for crossmatch
• Trauma panel – CBC, BMP, coags
Hemorrhagic Shock
Class I
EBL <750
Class II
750-1500
Class III
Class IV
1500-2000 >2000
HR
<100
>100
>120
>140
BP
NL
NL
LOW
LOW
UO
>30
20 - 30
5 - 15
MIN
ACS-COT 1993
Direct Effects of Hemorrhage
• Class I – (up to 15% blood volume loss)
Exemplified by the patient that has donated one
unit of blood
• Class II – (15% - 30% blood volume loss)
Uncomplicated hemorrhage for which crystalloid
fluid resuscitation is required
Direct Effects of Hemorrhage
• Class III – (30% - 40% blood volume loss)
Complicated hemorrhagic state in which at least
crystalloid infusion is required and perhaps also
blood replacement
• Class IV – (more than 40%)
Considered a pre-terminal event, and unless
very aggressive measures are taken, the patient
will die within minutes
Fluid Resuscitation
• Balance organ perfusion with risk of re-bleeding
– may reverse vasoconstriction of injured vessel
– Dislodge early clot
– Dilute coagulation factors
– Cool patient
– Induce visceral swelling
Too much fluid?
Adequacy of Resuscitation
Clinical Variables
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•
•
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•
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Mentation
Pulse, pulse pressure, BP
Urine output
Clot formation
Temperature
Lactate/base deficit
Primary Survey - Disability
Neurologic Evaluation
• Baseline neurologic evaluation
• GCS scoring
• Pupillary response
**Observe for neurologic deterioration
Head Trauma
• Severe CHI (GCS < 9) vulnerable to secondary
brain injury
• Hypotension doubles mortality
• Hypoxia and hypotension increases mortality
by 75%
• Normovolemia goal (dehydration harmful)
• Hypertonic saline or Osmotic Agent (mannitol)
Head Trauma
• Hyperventilation used cautiously
– only used if patient rapidly deteriorates
• PCO2 no lower than 30-35
• Prolonged hyperventilation can produce
cerebral ischemia and secondary brain injury
• Mannitol useful
– after adequate volume resuscitation
Spinal Cord Injury
• Neurogenic Shock
– Consider hemorrhage first…
• Maintain spine immobilization
• Fluid or no fluid?
• Vasopressors
Septic Shock
• Uncommon immediately after injury
• May occur several hours after injury
(especially if transfer to emergent facility
delayed)
• May occur in penetrating abdominal injuries
– contamination of intestinal contents into
peritoneal cavity
Primary Survey Exposure/Environmental Control
• Completely undress the patient
• Prevent hypothermia
Deadly Triad
• Hypothermia
• Acidosis
• Coagulopathy
Hypothermia (HT)
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•
•
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Frequent in trauma/massive transfusions
Trauma-related HT considered poor prognostic sign
Mortality directly  to degree and duration
Inhibits coagulation factor synthesis, prolongs PT and
PTT
• Severely affects platelet count and function
• Attenuates vital CV compensatory responses,
predisposes to arrhythmias
Re-warming
• Aggressive therapy associated with significant
decrease in:
– blood loss
– fluid requirements
– organ failure
– LOS in ICU
– mortality rate
Secondary Survey
• Begins after ABCDE is completed
• Resuscitative efforts underway
• Each region of the body is completely
examined
Trauma imaging
• Chest x-ray
• Pelvis x-ray
• FAST
– focused assessment sonography in trauma
• DPL (center-dependent)
– diagnostic peritoneal lavage
• CT scan
– Traumagram
Adjuncts Secondary Survey
• Foley
• NGT
• ABG/lactate
– If actively resuscitating
Primary Goal of Initial Operation
for a Trauma Patient
Damage Control
• Hemorrhage Control
• Contamination
Case Study #1
20 year old male, unrestrained driver, in a motor
vehicle that collides into a large tree. +LOC at
the scene and unresponsive. Starred
windshield. Life flight transported to VUMC.
VS: 120/70 mm Hg, HR= 110-115, RR= 15
Receiving oxygen 100% NRB
Question #1
What is the number one priority during the
initial assessment of this trauma patient?
1-Airway
2-Breathing
3-Circulation
4-Disability
Question #2
What Level One Criteria does the patient meet?
1- GCS < or = 8
2- Head injury with LOC > 5 min
3- moderate to severe respiratory distress
4- all the above
Question #3
True or False.
The patient’s need for airway protection and
ventilation is due to unconsciousness.
1- True
2- False
Question #4
Which two steps listed below are early steps in
the RSI procedure?
1- Pre-oxygenate with 80% oxygen & apply
cricoid pressure
2- perform chin lift/jaw thrust to open airway&
pre-oxygenate with 100% oxygen
3- administer a paralytic & ventilate
Question #5
How do I know the ETT is in the correct
position?
1- presence of CO2 in the end tidal CO2 detector
only?
2- equal breath sounds bilaterally and gurgling
in the epigastrium
3- presence of CO2, equal bilateral breath
sounds and CXR
Case Study #2
• 20 year old male assaulted. GSW to right
chest and left lower extremity. Patient is c/o
chest pain, SOB, and left lower extremity pain
• HR= 110; BP=120; RR = 30; SaO2= 90% on 100
% NRB; No BS on Right
Question #1
True or False.
This patient does not meet Level One Criteria.
1- True
2- False
Question #2
What trauma imaging is needed for this patient?
1- CXR only
2- CT of the chest
3- CXR, CT chest/abd/pelvis, Left femur XR
4- Head CT
What is wrong with this CXR?
Question #3
What do you think is wrong with this patient
based on the CXR provided?
1-labored breathing due to pain
2-spleen laceration
3-pneumothorax
4- hemothorax
Question #4
What should be assessed in the secondary
survey?
1-pulses of right leg only
2-roll the patient for posterior check
3-roll patient over (posterior check) and assess
pulses (Fem, DP,PT)
4-secondary survey excluded because the
patient states, “I am fine”
Case Study #3
18-20 year old male unrestrained passenger.
Car hit a bridge. Driver DOA. Reported by EMS,
“Initially awake, not acting right”. Gradually
more confused & verbally uncooperative. 2L NS
in air craft. BP=110 and decreasing. HR=120.
RSI per life flight.
Question #1
What signs/symptoms are the patient exhibiting
that he needs resuscitation?
1- decreased mentation
2- increasing HR and decreasing BP
3- Both
Question #2
The patient has increasing HR =130s BP= 84P
What stage of shock is the patient in?
1- Stage 1
2- Stage 2
3- Stage 3
4- Stage 4
Question #3
The patient was given 2L of NS during his flight
and was unresponsive to this. What is the next
step? BP 84P HR=130
1- order a 3rd liter of crystalloid
2- order 2 U PRBCs
3- do nothing
4- give 4 FFP
Question #4
What trauma imaging is needed at this time?
Secondary survey noted left lower abdominal
ecchymosis.
1- CXR
2- CT chest/abd/pelvis
3- FAST exam
4- one and two only
Question #5
True or False.
A FAST exam (focused assessment sonography)is
used to rapidly identify hemorrhage or potential
hollow viscous injury
1-True
2-False
Question #6
FAST study positive for a large amount of fluid in
the abd. What intervention is needed for the
patient at this time?
1- Go to the operating room
2- Activate the trauma exsanguination protocol
3- Go immediately to CT scan
4- Both one and two
Question #7
What is the trauma exsanguination protocol or
Massive transfusion protocol?
1- 2 L crystalloid
2- 2 U PRBC
3- 2 L crystalloid and 2 U PRBC
4- 6 U PRBC, 4 U FFP, 1 pack plts
References
• Acute Trauma Life Support Course – Retrieved from American
College of Surgeons Website
http://www.facs.org/trauma/atls/information.html on July 1,
2012.
• Guillamondegui, Oscar MD, MPH, FACS, Associate Professor of
Surgery, Medical Director, Trauma ICU, Director of Trauma
Education, Vanderbilt University Medical Center.
• Atkinson, S., Collins, N., Martin, M., Morton, M., Marshall, K.
(2012) Outcomes of Adding ACNPs to a Level One Trauma
Service with the Goal of Decreased Length of Stay and
Improved Patient, Physician and Nursing Satisfaction: A pilot
study.