Transcript Trauma

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
manoeuvres
• Impending airway obstr ( facial burns/
inhalation injury)
• GCS <9
• Haemorrhage from maxillofacial injuries
• Respiratory 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 10-12
Glidescope best
Secondary survey
History AMPLE
Undress pt and turn to
evaluate back
Avoid hypothermia
Systematically from head to
toe
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 45-60 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 80-100 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 50-60
• Heart rate: < 120 beats/min
• Oxygenation:
SpO2> 96%
• Urine output: > 0,5 ml/kg/ hour
• Mentation: follow commands
• Lactate level: < 1,6 mmol/l
• Base deficit: > -5
• 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
Cyclokapron
Antifibrinolitic
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
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
SPV
PPV
SVV
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 91
1. 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 CO2 30-35
Let temp drift down to 36 degrees
Prevent bucking against ETT