Transcript Trauma Resuscitation

Trauma Resuscitation
Yael Moussadji, R3
Emergency Medicine
“resuscitare”…
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Latin – to reanimate or revive
Refers to the diagnostic and therapeutic
maneuvers used to treat trauma patients
Defines restoration of physiologic parameters
Reversal of shock
Objectives
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To review how to improve your efficiency in a
trauma resuscitation
To review the pathophysiology of trauma and
the keys to stabilizing your patient
To discuss (briefly) the controversies around
fluid resuscitation
To discuss pre-hospital considerations and the
trauma system at large
Epidemiololgy and the Trauma System
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Trauma is a disease of the young and is the No. 1
cause of death in people aged 1-37
Among fatal MVCs, 38% are associated with alcohol
and drug use, and only 37% were wearing seatbets
Regionalization of trauma care first came about in the
1970s with the creation of the first trauma centre at the
University of Maryland
Now regional planning with designated trauma centres
is essential, and involves ambulance destination
polices and quality assurance programs to monitor
patient outcomes
Prehospital Considerations
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The appropriate management of patients in the
prehospital setting has been complicated by
well intentioned traditional attempts to simplify
it
The controversial issues most impact patients
with post-traumatic internal hemorrhage and
post-traumatic circulatory arrest
Tenants of Prehospital Trauma Care
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Prevention of additional injury
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Careful extrication, spinal immobilization, spliting
Rapid transport
Advance notification to trauma facility
Field interventions
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Spinal immobilization, airway management, restoration of
circulating volume
Post-traumatic hemorrhage
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In 1994, a large prospective controlled clinical trial comparing
immediate prehospital and ED fluid resuscitation with delayed
resuscitation until arrival in the O.R. found that hypotensive
patients with penetrating torso injuries did worse if they received
early resuscitation with crystalloids (higher mortality, more post-op
complications)
It is postulated that elevated SBP results in mechanical disruption
of soft clot and dilution of clotting factors, accelerating ongoing
hemorrhage
No studies have correlated fluid resuscitation with increased
survival
Key factors in the survival of critically injured patients are limited to
rapid transport to an appropriate facility and aggressive airway
control
Guidelines for fluid administration
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Despite the recent evidence, the American
College of Surgeons recommendations for
trauma resuscitation still maintain that an initial
infusion of LR or NS is the standard of care for
the initial treatment of hemorrhagic shock
It may be prudent however to undertake a
moderate resuscitation for patients with
uncontrolled vascular injuries of the torso (with
the exception of the moribund patient)
Trauma-associated circulatory arrest
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Implies that although the patient may be pulseless and
apneic, the heart may still be beating (hypovolemia,
tamponade, pneumo)
Survival is associated with younger age, single organ
involvement, less than 10 min to surgical intervention,
rapid prehospital ETI with slow (6-8 breaths/min)
controlled ventilations (aggressive ventilation can
severely impair cardiac output)
“Scoop & Treat” vs “Scoop & Run”
Conducting a Resuscitation
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The trauma bay
Resuscitation physicians
Paradigms of
resuscitation
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Horizontal resuscitation –
one physician performs
the primary and
secondary surveys in
their entirety
A second physician
performs procedures as
they come up
The Trauma Team
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Success of a horizontal resuscitation depends on each member of
the team understanding and executing her role while the identified
team leader (YOU!) keeps control and makes treatment decisions
For all Level 1 traumas in our trauma system, EP’s act as the
assessment physician and conduct the initial primary +/secondary surveys; stand to the patients right near the head and
verbalize your findings loudly
If a procedure physician is available, he or she is positioned on
the patients left and may need to perform chest thoracostomy,
central line insertion, splinting etc
Trauma nurses are positioned on each side of the patient and are
responsible for ECG monitoring, vital signs, labs, IV access and
fluid administration
Hemorrhage and Shock
Goals
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Securing the airway, maintaining ventilation, controlling
hemorrhage and reversing shock
Trauma deaths show a trimodal distribution;
immediately, within the first 24 hours, in the next 3-4
weeks; MOF is the leading cause of mortality in
patients who survive the initial resuscitation and
surgical intervention
Failure to adequately resuscitate in the ER can lead to
acidosis, hypothermia, and coagulopathy, resulting in
MOF and death
ISS, age, platelet count on admission, and lactate at 12
hours are all predictors of the development of MOF
Shock
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Basic cellular derangement involves an imbalance of oxygen
utilization
SIRS and MOF is on the far end of a continuum initated and
perpetuated by inflammation and inflammatory mediators
Acute hemorrhage causes decreased CO and pulse pressure,
resulting in tachycardia, vasoconstriction and redistribution of
blood flow away from non-vital organs and initiating a multihormonal response
Aim is to stabilize and reverse these derangements before
damage is done to individual organ systems
Base deficit is an indirect measure of lactate production and a
reliable indicator of shock; lactate correlates with depth of shock
and is a predictor of mortality
Priorities in Management
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Assess and manage the airway and ventilation simultaneously
(ETI, CXR, thoracostomy)
Control external hemorrhage with manual pressure, obtain
vascular access, and begin volume resuscitation with crystalloids
+/- blood
Identify source of hemorrhage: ongoing blood loss causing
hypotension can usually be found in the chest, abdomen, or
retroperitoneum
Conduct of thorough exam with frequent reassessments of the
ABCs; incorporate the X-rays of the chest and pelvis and the
FAST into your primary survey
Always protect the C-spine; obtain X-rays once stable
Resuscitation Fluid
Colloid vs Crystalloid
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A large evidence based review of more than 82 studies comparing
crystalloid to colloid resuscitation was published by the McMaster
group in 1999 (Crit Care Med); there was no overall difference in
mortality, pulmonary edema, or length of stay, but there was a
trend toward better survival in trauma patients with crystalloid use
(poor confidence intervals)
In order to show a significant difference in mortality, an RCT would
have to enroll more then 9000 patients
In a systematic review of 30 studies with 1419 patients, albumin
has been shown to increase risk of death
Overall the greatest difference is the exhorbitant cost of colloids
compared to crystalloids
Therefore, colloid resuscitation cannot be recommended for
routine use in the resuscitation of patients with hemorrhagic shock
NS or LR
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The non-anion gap acidosis that has been noted with
NS use is not secondary to hyperchloremia, but in fact
a lactic acidosis secondary to hypoperfusion
LR improves this acidosis because the lactate isomer
is converted to bicarb, which acts as a buffer
Adequate resuscitation returns the pH to normal
regardless of which fluid is used
NS is preferred in patients with TBI because of the
slight hypertonicity (154mmol/L)
Blood
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The decision to transfuse is made after consideration
of mechanism of injury, hemodynamic status, response
to crystalloid infusion, and pre-morbid status
In general, all trauma patients should receive a 2 L
crystalloid infusion first
If they remain hemodynamically unstable or have had
significant blood loss, begin transfusing immediately; 2
units of O neg (O pos in men) wide open through a
fluid warmer
Transfusion Triggers
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One large multicentre RCT showed that receving transfusions to a
Hg threshold of 90 conferred no physiologic benefit compared to
70, and in younger patients with less severe illness the mortality
was higher (some benefit noted for patients with AMI and UA)
Patients with massive transfusions are at a higher risk of dying
from their injuries; independent predictors of mortality include
persistent hypotension, inotrope requirements intra-operatively,
and need for cross clamping of the aorta; interestingly, the amount
of units of blood transfused was not an independent predictor of a
bad outcome
Therefore massive transfusion requirements cannot be used as an
indicator to discontinue resuscitation efforts
Other Blood Products
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During large volume transfusions of PRBCs,
other blood products must be given
As a guideline, give 2 units FFP for every 4-6
units of PRBCs (and when INR is elevated)
Platelet counts <100 are common in severe
trauma; patients with ongoing bleeding should
receive 6-10 units of platelets
Approach to the Secondary Survey
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Neurologic exam
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Thoracic exam
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Insertion of OG and foley, urine for R+M
Cardiac exam
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Always remember to inspect and feel the chest wall for
contusions, bony crepitus, flail segments, SC emphysema
Abdominal exam
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LOC, pupils, H/N, CNs, TMs, spinal cord function, peripheral
nerve exam
Ability to move extremities and sense pain indicates intact cord
ECG
MSK exam
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Identify deformity, swelling, tenderness; check pulses
Diagnostic Imaging in Trauma
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For the critically ill patient, incorporate X-rays of the chest and
pelvis into your primary survey; C-spine series early for the stable
moderately injured patient
FAST can also be incorporated into the primary survey for the
detection of hemoperitoneum and the identification of patients who
need immediate laparotomy
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Assesses heptorenal recess, splenorenal recess, and
rectovesicular recess for free fluid; false negative scans
commonly involve bowel perfs, contained liver or spleen lacs
Also evaluates for pericardial fluid
Stable patients can be further assessed by CT, which is the gold
standard in identifying location and extent of solid organ injury,
presence of aortic or thoracic injury
Special Situations
Closed Head Injury
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Hemorrhagic shock with CHI portends a poor
prognosis; persistent hypotension is one of the worst
prognostic indicators for recovery
Treatment aimed at restoring BP, controlling bleeding,
assuring adequate CPP
Diagnosis and treatment of hypotension always takes
precedence over the head injury
Defer head CT in patients with evidence of intraabdominal bleeding and hypotension – they need a
laparotomy
Do not withhold fluids for fear of cerebral edema;
consider HTS as a resuscitation fluid
Spinal Cord Injury
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Neurologic shock and hemorrhagic shock can occur
simultaneously; treat first as presumed blood loss
Both are treated with aggressive fluid resuscitation
If bleeding has been excluded, vasopressors are
indicated after adequate volume loading
Patients in neurogenic shock are inappropriately
vasodilated and often bradycardic due to a loss of
sympathetic tone
Dopamine is the drug of choice for its chronotropic,
inotropic, and vasoconstrictive effects
The Elderly
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Age alone is not a predictor or morbidity and mortality
in trauma
However, elderly patients have less physiologic
reserve, more premorbid conditions, and less ability to
compensate for injury
Vascular compliance, myocardial reserve, and bone
strength are compromised
Heart disease is the leading premorbid condition that
puts elderly patients are higher risk of complications
Consider medications (beta-blockers, coumadin)
The Pediatric Patient
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The majority of pediatric blunt trauma patients can be
resuscitated and treated non-operatively with great
success
All grades of liver, spleen, and kidney injuries can be
managed non-operatively
Laparotomy has been shown to increase blood loss
and transfusion requirements over successful nonoperative management
Therefore children should be treated based on their
response to resuscitation, not their injury
Conclusion
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Preparation is key!
Own the room. Become comfortable and
efficient as a team leader.
Rapid resuscitation and stabilization is where
we can have the most impact on our patients