Transcript Trauma System

Trauma
Zhanfei Li. MD &PhD
Associate professor and attending surgeon
Division of Traumatic Surgery, TJH
Introduction

Trauma is a major worldwide
public health problem.

It is one of the leading causes
of death and disability in both
industrialized and developing
countries.
st

In the US, trauma is the 1
cause of death in children and
adults <45 years of age.

It is called “the disease of the
civilized society”.
Incidence of Trauma
 Leading cause of death in U.S. in patients less than 45
years old (CDC 2004)
 60 million injured
 160,000 die – (56/100,000) and the rate is going up
 9 million disabled - 300,000 permanently
 Trauma is more commonly a disease of the young (1534) thus has a far greater economic impact
 Significant yearly economic cost
Why do Trauma Patients Die?
 Some are killed immediately from massive injuries (can’t
help these except by prevention)
 Many die from head injuries---Rapid care can save many of
these
 Many bleed to death
 bleeding may not be initially recognized
These patients may die while waiting for transfer to a
trauma hospital
 Some die later of complications (organ failure or sepsis)
Survival is often related to how soon the bleeding was
stopped and blood volume restored
Mortality after traumatic injury
 One half of trauma deaths occur within seconds or minutes
due to injury of aorta, heart, brain, etc.
 Very few of these victims can be saved by trauma systems.
 The second mortality peak occurs within hours of injury and
accounts for ~30% of deaths. The major causes of deaths are
massive hemorrhage and brain injury.
 The third mortality peak occurs in 24hours after injury, mainly
after 1 week. The major causes are infection, sepsis and MOF.
Tri-modal distribution of injury-related death
Within seconds
and minutes
Three peak of injury-related death
Within hours
Hemorrhage
and brain injury
Golden hour
>24hours and later
Infection and MOF
The Golden Hour
转运
损伤
初始评估
（初步检查）
病情稳定
第一小时
从头到脚评估
（再次检查）
挽救生命的干预
（复苏）
Development of trauma care
 Modern trauma care has evolved from the close relation of surgery
and casualty management in war.
 Many important concepts, including prehospital transport, volume
resuscitation, life support and critical care have been advanced
based on the observations during war.
 The first organized trauma unit opened in 1961 at the University of
Maryland.
 Trauma care requires collaboration of pre-hospital care, ER,
multiple disciplines (general surgery, neurosurgery, orthopaedic
surgery, thoracic surgery, vascular surgery, as well as rehabilitation.
A System Saving Lives
SURVIVOR OR STATISTIC?
Trauma System
 Organized system within a given
region including prehospital care,
acute hospital care, and rehabilitation
Trauma System
A trauma system involves trauma
centers working together with 91-1, EMTs, ambulances,
helicopters, and other health
care resources in a coordinated
and preplanned way. This
network of care is designed to
get seriously injured people to
the place with the right
resources as quickly as
possible
Development of trauma care system
Components of
trauma care
rehabilitation
First aid
Trauma
system
Traumatic
surgery/ICU
OR
Re-evaluation and
advanced life support
ER
Why is it important?
 Multiple studies show that care
in a trauma system has:
 Decreased mortality of 10-30%
 Reduced disability
 Improved quality of care
 Cost savings
Trauma Center
Trauma centers are selected hospitals that provide a full
range of care for severely injured patients 24 hours a
day, seven days a week. The trauma care includes
ready-to-go teams that perform immediate surgery and
other necessary procedures for people with lifethreatening injuries, for example, due to car accident,
burn, bad fall, or gunshot.
Trauma Center
 Hospital that meets certain
readiness requirements for care
of injured persons
 Categorized by level (usually 1
through 4) by capacity/
capability
 Involves having the right
personnel and equipment
readily available for trauma care
Trauma Center Designation
T
T
How does the System Save Lives?
 It correctly identifies the patients who need trauma care
 Anticipates the resources needed to treat the patients
 Locates the available needed resources
 Routes the patient “right” the first time to reduce time to
appropriate care
 Arranges interfacility transfers if needed to reduce time to
appropriate care
 Improves care by the QI process and Research activity
Who is a “Trauma System” Patient?
 A “trauma” patient is any patient who is injured
 Most injuries are minor and should be treated at a local
community hospital
 Less than 10% of patients with injuries need to go to a trauma
center. These are Trauma System patients.
 A “Trauma System” patient has life-threatening injuries that
require rapid, specialized care. Examples are:
 Injured patients with signs of shock
 Injured patients with airway problems
 Head or spinal injuries
 Multiple long bone fractures
 Ejection from vehicle
 Major burns or smaller burns with other injuries
This is an Trauma Patient but not a
Trauma System Patient
Fracture-Dislocation of the Ankle
骨折-踝关节脱位
This is a Trauma System Patient
What are the Qualities of a Good
Trauma System?
 Network of hospitals with the commitment and the
resources to care for trauma system patients
 Organized plan to route critical patients to the right
hospital that is ready to care for them
 Constant monitoring of the system to correct
problems, improve the system, and validate the
quality of care provided
Elements of an Effective Trauma SYSTEM
 Effective pre-hospital providers and protocols
 Designated trauma centers (hospitals designated Level 1-4)
 Trained and available physician trauma specialists and
nurses
 Rehabilitation facilities
 Trauma registry
 Continuous quality improvement
 Communication and coordination
 Injury Prevention and Control programs
INITIAL EVALUATION AND RESUSCITATION
OF THE INJURED PATIENT
Primary Survey

Airway Management with Cervical Spine Protection

Breathing and Ventilation

Circulation with Hemorrhage Control

Disability and Exposure

Shock Classification and Initial Fluid Resuscitation
Secondary Survey
Primary survey

Airway Management with Cervical Spine Protection

Breathing and Ventilation

Circulation with Hemorrhage Control

Disability and Exposure

Shock Classification and Initial Fluid Resuscitation

Persistent Hypotension
Initial management of trauma patients
VIPC
ABCDE
CRASH
PLAN
Principle: the No1 priority is to save the life of patients,
the second one is to reserve function of organs
VIPC
V: Ventilation
I: Infusion
P: Pulsation
C: Control bleeding
ABCDE
A=airway
VIPC
V: Ventilation
B=breath
C=circulation
I: Infusion
D=disability
E=exposure for
P: Pulsation
complete examination
C: Control bleeding
Crash Plan
Crash Plan
C=cardiac
P=pelvis
R=respiratory
L=limb
A=abdomen
A=arteries
S=spine
N=nerves
H=head
Airway Management with Cervical Spine Protection

Ensuring a patent airway is the first priority in the primary
survey. This is essential, because efforts to restore
cardiovascular integrity will be futile unless the oxygen
content of the blood is adequate.

Simultaneously, all patients with blunt trauma require cervical
spine immobilization until injury is excluded. This is typically
accomplished by applying a hard collar or placing sandbags
on both sides of the head with the patient’s forehead taped
across the bags to the backboard.
Airway Management with Cervical Spine Protection
 Patients who have an abnormal voice, abnormal
breathing sounds, tachypnea, or altered mental status
require further airway evaluation.
 Cricothyroidotomy is performed through a generous
vertical incision, with sharp division of the subcutaneous
tissues and strap muscles. Visualization may be improved
by having an assistant retract laterally on the neck
incision using army-navy retractors.
Cricothyroidotomy
 Cricothyroidotomy is
recommended for
emergent surgical
establishment of a
patent airway.
A. Use of a tracheostomy hook stabilizes the thyroid
cartilage and facilitates tube insertion.
B. A 6.0 tracheostomy tube or endotracheal tube is
inserted after digital confirmation of airway access.
Tracheostomy

Emergent tracheostomy is indicated in patients with
laryngotracheal separation or laryngeal fractures, in
whom cricothyroidotomy may cause further damage or
result in complete loss of the airway
Breathing and ventilation
 Once a secure airway is obtained, adequate oxygenation
and ventilation must be assured. All injured patients
should receive supplemental oxygen and be monitored by
pulse oximetry.
Breathing and ventilation
 The following conditions constitute an immediate threat to
life due to inadequate ventilation and should be
recognized during the primary survey:
tension pneumothorax
open pneumothorax
flail chest with underlying pulmonary contusion
 All of these diagnoses should be made during the initial
physical examination.
Tension pneumothorax
 The diagnosis of tension pneumothorax is implied by
respiratory distress and hypotension in combination with
any of the following physical signs in patients with chest
trauma:
tracheal deviation away from the affected side
lack of or decreased breath sounds on the affected side
subcutaneous emphysema on the affected side
Tension pneumothorax
 In cases of tension pneumothorax, the paren-chymal
tear in the lung acts as a one-way valve, with each
inhalation allowing additional air to accumulate in the
pleural space.
 The normally negative intrapleural pressure becomes
positive, which depresses the ipsilateral hemidiaphragm
and shifts the mediastinal structures into the
contralateral chest.
Tension pneumothorax
 Subsequently, the contralat-eral lung is compressed and
the heart rotates about the superior and inferior vena
cava;
 This decreases venous return and ultimately cardiac
output, which results in cardiovascular collapse.
Tension pneumothorax
 Vital signs differentiate a tension pneumothorax from a
simple pneumothorax; each can have similar signs,
symptoms, and examination findings, but hypotension
qualifies the pneumothorax as a tension pneumothorax.
Tension pneumothorax-therapy
 Although immediate needle
thoracostomy decompression
with a 14-gauge
angiocatheter in the second
intercostal space in the
midclavicular line may be
indicated in the field, tube
thoracostomy should be
performed immediately in the
ED before a chest radiograph
is obtained
Open pneumothorax
 An open pneumothorax or “sucking chest wound” occurs
with full-thickness loss of the chest wall, permitting free
communication between the pleural space and the
atmosphere.
 This compromises ventilation due to equilibration of
atmospheric and pleural pressures, which prevents lung
inflation and alveolar ventilation, and results in hypoxia
and hypercarbia.
Open pneumothorax-therapy
 Temporary management of this
injury includes covering the wound
with an occlusive dressing that is
taped on three sides.
 This acts as a flutter valve,
permitting effective ventilation on
inspiration while allowing
accumulated air to escape from the
pleural space on the untaped side,
so that a tension pneumothorax is
prevented.
 Definitive treatment requires
closure of the chest wall defect and
tube thoracostomy remote from the
wound.
Flail chest
 Flail chest occurs when three or more contiguous ribs
are fractured in at least two locations. Paradoxical
movement of this free-floating segment of chest wall may
be evident in patients with spontaneous ventilation, due
to the negative intrapleural pressure of inspiration.
Flail chest
 Rarely the additional work of breathing and chest wall
pain caused by the flail segment is sufficient to
compromise ventilation.
 However, it is the decreased compliance and increased
shunt fraction caused by the associated pulmonary
contusion that is typically the source of postinjury
pulmonary dysfunction.
Flail chest
 Pulmonary contusion often progresses during the first
12 hours. Resultant hypoventilation and hypoxemia may
require presumptive intubation and mechanical
ventilation.
Flail chest-therapy
A
 The patient’s initial chest
radiograph often
underestimates the extent of
the pulmonary parenchymal
damage;
B
 Close monitoring and
frequent clinical reevaluation are warranted
Circulation with hemorrhage control
 With a secure airway and adequate ventilation
established, circulatory status is the next priority.
 An initial approximation of the patient’s cardiovascular
status can be obtained by palpating peripheral pulses.
 In general, systolic blood pressure (SBP) must be
60mmHg for the carotid pulse to be palpable, 70 mmHg
for the femoral pulse, and 80 mmHg for the radial pulse.
Circulation with hemorrhage control
 At this point of patient evaluation, any episode of
hypotension (defined as a SBP <90 mmHg) is assumed
to be caused by hemorrhage until proven otherwise.
 Patients should be closely monitored until normal vital
sign values are restored.
Circulation with hemorrhage control
 IV access for fluid resuscitation
is obtained with two peripheral
catheters, 16-gauge or larger in
adults.
 Blood should be drawn
simultaneously and sent for
measurement of hematocrit level,
as well as for typing and crossmatching for possible blood
transfusion in patients with
evidence of hypovolemia.
Circulation with hemorrhage control

External control of hemorrhage should be achieved
promptly while circulating volume is restored. Manual
compression of open wounds with ongoing bleeding
should be done with a single 44 gauze and a gloved hand.
 Blind clamping of bleeding vessels should be avoided
because of the risk to adjacent structures, including nerves.
Circulation with hemorrhage control
 During the circulation section of the primary survey, four
life-threatening injuries that must be identified are:
 (a) massive hemothorax
 (b) cardiac tamponade
 (c) massive hemoperitoneum
 (d) mechanically unstable pelvic fractures.
Massive hemothorax
 A massive hemothorax (life-threatening injury number one)
is defined as >1500 mL of blood or, in the pediatric
population, one third of the patient’s blood volume in the
pleural space
Massive hemothorax
FIG. 7-8. More than 1500 mL of blood in the pleural space is a massive
hemothorax. Chest film findings reflect the positioning of the patient. A. In
the supine position, blood tracks along the entire posterior section of the
chest and is most notable pushing the lung away from the chest wall. B.
In the upright position, blood is visible dependently in the pleural space.
Massive hemothorax
 After blunt trauma, a hemothorax usually is due to multiple
rib fractures with severed intercostal arteries, but
occasionally bleeding is from lacerated lung parenchyma.
 After penetrating trauma, a systemic or pulmonary hilar
vessel injury should be presumed. In either scenario, a
massive hemothorax is an indication for operative
intervention
 Tube thoracostomy is critical to facilitate lung re-expansion,
which may provide some degree of tamponade.
Massive hemothorax
 X-ray and CT image of hemothorax
Cardiac tamponade
 Cardiac tamponade (life-threatening injury number two)
occurs most commonly after penetrating thoracic injuries,
although occasionally blunt rupture of the heart,
particularly the atrial appendage, is seen.
 Acutely, <100mL of pericardial blood may cause
pericardial tamponade.
Cardiac tamponade
Beck’s triad
临床工作
Dilated neck veins
Muffled heart tones
Decline in arterial
pressure
 The classic diagnostic
Beck’s triad—dilated
neck veins, muffled heart
tones, and a decline in
arterial pressure—often
is not observed in the
trauma bay because of
the noisy environment
and hypovolemia.
Cardiac tamponade
 Because the pericardium is not acutely distensible, the
pressure in the pericardial sac will rise to match that of
the injured chamber.
Cardiac tamponade
 Because the pericardium is not acutely distensible, the
pressure in the pericardial sac will rise to match that of
the injured chamber.
 When this pressure exceeds that of the right atrium, right
atrial filling is impaired and right ventricular preload is
reduced. This leads to decreased right ventricular output
and increased CVP.
 Increased intrapericardial pressure also impedes
myocardial blood flow, which leads to subendocardial
ischemia and a further reduction in cardiac output.
Cardiac tamponade
Figure: Subxiphoid pericardial ultrasound reveals a large
pericardial fluid collection
 Diagnosis is best achieved by bedside ultrasound of
the pericardium
Cardiac tamponade
 Removing as little as 15 to 20 mL of blood will often
temporarily stabilize the patient’s hemodynamic status,
prevent subendocardial ischemia and associated lethal
arrhythmias, and allow transport to the OR for
sternotomy.
 Pericardiocentesis is successful in decompressing
tamponade in approximately 80% of cases; the majority
of failures are due to the presence of clotted blood within
the pericardium.
Cardiac tamponade
 Patients with a SBP<70 mmHg warrant emergency
department thoracotomy (EDT) with opening of the
pericardium to address the injury.
 The utility of EDT has been debated for many years.
Current indications are based on 30 years of prospective
data.
Cardiac tamponade
Massive hemoperitonium and unstable
pelvic fracture
 Three critical tools used to differentiate these in the
multisystem trauma patient are chest radiograph, pelvis
radiograph, and focused abdominal sonography for
trauma (FAST)
Disability and exposure
 Glascow coma score (GCS) should be determined for all
injured patients.
 An abnormal mental status should prompt an immediate
re-evaluation of the ABCs and consideration of central
nervous system injury.
 Deterioration in mental status may be subtle and may not
progress in a predictable fashion.
GCS（Glascow coma score）is used to evaluate
the consciousness of the patient
Disability and exposure
 Seriously injured patients must have all of their clothing
removed to avoid overlooking limb- or life-threatening
injuries.
Shock classification and initial fluid resuscitation
Shock classification and initial fluid resuscitation
 Classic signs and symptoms of shock are tachycardia,
hypotension, tachypnea, mental status changes,
diaphoresis, and pallor The quantity of acute blood loss
correlates with physiologic abnormalities.
 Physical findings should be viewed as a constellation
and aid in the evaluation of the patient’s response to
treatment.
Shock classification and initial fluid resuscitation
 The goal of fluid resuscitation is to re-establish tissue
perfusion. Fluid resuscitation begins with a 2 L (adult) or
20 mL/kg (child) IV bolus of isotonic crystalloid, typically
Ringer’s lactate.
 For persistent hypotension, this is repeated once in an
adult and twice in a child before red blood cells (RBCs)
are administered.
Shock classification and initial fluid resuscitation
 Urine output is a quantitative, reliable indicator of organ
perfusion.
 Adequate urine output is 0.5 mL/kg per hour in an adult,
1 mL/kg per hour in a child, and 2 mL/kg per hour in an
infant <1year of age.
 Measurement of urine output is time-dependent.
Pitfalls in evaluation for patients with shock
 Relative tachycardia or tachycardia caused by other
conditions
 Hypotension is not a reliable sign for hypovolemia,
because blood volume must decrease by >30% before
hypotension occurs.
Goals of shock resuscitation
 The role of shock treatment in ER remains controversial.
Restrictive fluid
resuscitation
TBI
Hemorrhage
SBP>90mmHg
SBP<90mmHg?
Shock resuscitation
Secondary survey
 Once the immediate threats to life have been addressed,
a thorough history is obtained and the patient is examined
in a systematic fashion.
 The patient and surrogates should be queried to obtain
an AMPLE history (Allergies, Medications, Past illnesses
or Pregnancy, Last meal, and Events related to the
injury).
 The physical examination should be head to toe, with
special attention to the patient’s back, axillae, and
perineum, because injuries here are easily overlooked.
Secondary survey
 All potentially seriously injured patients should undergo
digital rectal examination to evaluate for sphincter tone,
presence of blood, rectal perforation, or a high-riding
prostate; this is particularly critical in patients with
suspected spinal cord injury, pelvic fracture, or
transpelvic gunshot wounds.
 Vaginal examination with a speculum also should be
performed in women with pelvic fractures to exclude an
open fracture.
Secondary survey
 Adjuncts to the physical examination include:
 vital sign and CVP monitoring
 ECG monitoring
 nasogastric tube placement
 Foley catheter placement
 repeat FAST
 laboratory measurements
 and radiographs.
Secondary survey
 A nasogastric tube should be inserted in all intubated
patients to decrease the risk of gastric aspiration but
may not be indicated in the awake patient.
 Placement of a nasogastric tube is also contraindicated
in patients with complex facial fractures.
 A Foley catheter should be inserted in patients unable to
void to decompress the bladder, obtain a urinespecimen,
and monitor urine output.
Secondary survey
 Selective radiography: lateral cervical, chest and pelvic
(big three)
 Laboratory test: blood routine, Hg quantitation, WBC and
differential, Plt, urine routine, etc.
Primary and secondary survey
ABCDE
A=airway
VIPC
V: Ventilation
B=breath
C=circulation
D=disability
E=exposure for complete
examination
Crash Plan
C=cardiac
R=respiratory
A=abdomen
I: Infusion
S=spine
H=head
P: Pulsation
C: Control bleeding
P=pelvis
L=limb
A=arteries
N=nerves
General principles of management
 Remarkable changes in management practices and
operative approach for the injured patients in the past 20
years .
 Nonoperative management of solid organ injuries has
replaced routine operative exploration. Those patients
who do require operation may be treated with less
radical resection techniques such as splenorrhaphy or
partial nephrectomy.
 Emerging of damage control surgery (DCS)
Damage control surgery
 The recognition of the bloody vicious cycle and the
introduction of damage control surgery (DCS) have
improved the survival of critically injured patients.
 The bloody vicious cycle, first described in 1981, is the
lethal combination of coagulopathy, hypothermia, and
metabolic acidosis.
Damage control surgery
 Hypothermia occurs despite
the use of warming blankets
and blood warmers.
 The metabolic acidosis of
shock is exacerbated by
aortic clamping,
administration of
vasopressors, massive
transfusions, and impaired
myocardial performance.
 Coagulopathy is caused by
dilution, hypothermia, and
acidosis.
Damage control surgery
Coagulopathy
Core
hypothermia
Metabolic
acidosis
 Once the cycle starts, each
component magnifies the
others, which leads to a
downward spiral and
ultimately a fatal arrhythmia.
 The purpose of DCS is to
limit operative time so that
the patient can be returned to
the SICU for physiologic
restoration and the cycle thus
broken.
Damage control surgery
 Indications to limit the initial operation and institute DCS
techniques include:

temperature <35°C (95°F)

arterial pH <7.2, base deficit <15 mmol/L (or <6 mmol/L
in patients over 55 years of age),

INR or PTT >50% of normal.
 The decision to abbreviate a trauma laparotomy is made
intraoperatively as laboratory values become available
and the patient’s clinical course becomes clearer.
Evaluation of the severity of injured patients
AIS-ISS system
Abbreviated injury score (AIS): assess the severity
of injury and give a score from 1 to 6.
Injury severity score (ISS): this system divides the
whole body into 6 parts, head and neck, facial,
thorax (including the thoracic spine), abdomen and
pelvic viscera, limbs and pelvis, skin. ISS is the of
square of three most severe AIS
Comparison of the medical education System in
China and USA
USA
High school
China
BA
Medical school (BA)
B,C
A
Master’s degree
Medical School (MD)
B
Residency
MD program
B
Fellow
Specialist
Specialist
A:USMLE; B: equivalent; C: be accredited
by UBME
Medical Education System in USA
High school
BA
Medical
Students
Residency
Fellow
Specialist
International
Medical Graduates
USMLE
Step 1-2
USMLE
Step3
General
practice
Zhanfei Li. MD&PhD
Division of Traumatology, TJH of HUST
www.chinatrauma.cn