Trauma Resuscitation

Compliance with Trauma Guidelines reduces Mortality

including damage control, transfusion, and ventilatory management (Crit Care Med 2012;40:778)   use full body ct scout as lodox for bullet location

Falls from Height

LD90 for fall=7 stories The median lethal dose (LD50) for falls is 4 stories, or 48 ft, and the lethal does for 90% (LD90) of test subjects is 7 stories, or 84 ft. Reference: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. 4th ed. Mosby-Year Book, Inc; 1998:352.   Prognostic factors are height, impact surface, and the body part which first hits the ground (Crit Care Med 2005;33:1239) Over 50% in autopsy study had cardiac trauma (in half of these, it was the cause of death), consider thoracotomy (J Trauma 2004;57:301)       ABCs in trauma room often stand for Accuse, Blame, and Criticize, Deny, Exaggerate Anaesthetic ABCD:AvoidBlockCancelDefer Consultant> A appear> B blame> C criticize> D disappear   power vacuum needs to be filled   Airway-Ask patient to take deep breath (Gives A,B, and LOC) Breathing Circulation Search For Bleeding Disability (pupils/moves extremities) Expose and then cover (Strip, Flip, Touch, and Smell) Finger (rectal)/FAST Exam/Foley Glucose/Girl (pregnancy test) Hang Antibiotics Inject (tetanus)   Primary Survey Secondary Survey Tertiary Exam The tertiary exam was first introduced in 1993 by Enderson et al to assist with the diagnosis of any injuries that were not identified during the primary and secondary survey. The tertiary survey involved repetition of the primary and secondary surveys, meticulous physical examination, repetition of the history of the trauma history, and review of all laboratory and radiographic studies. These authors’ use of this tertiary survey resulting in diagnosis of missed injuries in 36 of 399 patients (9%). The most common reason for injuries to be missed was altered level of consciousness. None of the missed injuries resulted in death, but one missed injury resulted in disability and seven required operative intervention. In a second large series, a tertiary trauma survey detected 56% of the injuries missed during the initial assessment within 24 hours of admission.   Military is switching to <C>ABC for catastrophic hemorrhage to urge immediate use of tourniquets, dressings, and hemostatic agents BATLS (Emerg Med J 2006;23:745)       Consider an A-line if they need blood or pressors for hypotension

Lab Tests

Lactate/Base Deficit probably more useful then serial crits Clearance of 20% each hour is probably a good predictor of adequate resuscitation (Anesthesiology 2012; 117:1276-88) Venous base deficit correlated perfectly with arterial in trauma patients (J Trauma. 2011;71: 793–797) Study of serial crits (Injury 2006;37:46) Delta crit @ 4 hours had only 40% sensitivity, specificity of 95%. LR- 0.64 LR+ 7.1 One study shows 90% sensitivity??? for serious bleeds (J Trauma 2007;63:312) over 30 minutes Drop of 6 should warn of ongoing bleeding (Change in Hematocrit during Trauma Assessment Predicts Bleeding Even with Ongoing Fluid Resuscitation Authors: Thorson, Chad M.; Ryan, Mark L.; Van Haren, Robert M.; Pereira, Reginald; Olloqui, Jeremy; Otero, Christian A.; Schulman, Carl I.; Livingstone, Alan S.; Proctor, Kenneth G. Source: The American Surgeon, Volume 79, Number 4, April 2013 , pp. 398-406(9))

Airbags

Sodium azide is contained in airbags, shot c spark causing huge gas

expansion and releasing talc, if airbag doesn’t properly deploy, then can get NaOH (sodium hydroxide,) which can give contact dermatitis

Pain Management

Use fentanyl 1-2 ug/kg instead of morphine Consider SQ Ketamine .25 mg/kg then .1 mg/kg/hr. Use 26 gauge cannula in the SubQ space on the anterior abd wall. Avoid if possibility of head injury (?)

Fluid Resuscitation

delayed fluid resuscitation in penetrating torso injuries resulted in shorter hospitalization and less complications (NEJM 331:17; 1105-1109 Oct 1994)

Shock

Blood: external chest abd retroperitoneal pelvis long bone Non-Blood: pneumo tamponade myocardial contusion spinal shock   do not assume aortic injury is the cause of shock   “janitorial injuries” Best article on traumatic aortic disruption Fabian J Trauma 1997 42:374   new strategy of delayed aortic repair with BP/HR monitoring and control   Brain injury article J Trauma 1993 34:216   Mannitol has to be given by bolus not continuous infusion to be beneficial     pelvis injuries lateral compression horizontal fracture of the anterior ring look at the sacrum’s arcuate lines vertical shear, tape the feet together hemoperitoneum goes to the OR first, otherwise to angio suite     put pinky in sternal notch, index finger will be in the cricothyroid   Not true 80/70/60 pulse rule, but they will disappear in the predictable manner (Deakin et al BMJ Sept 2000)   do not need plain films after getting ct abd/pelvis, just reformat (J Trauma 55(4):665, October 2003)   Levels of Trauma Center Shitstorm SNAFU FUBAR AMF YoYo       Farming-manure to vegetables   Scalea TM et al: Central venous blood oxygen saturation: an early, accurate measurement of volume during hemorrhage. J Trauma 28:725, 1988;   “Rookies talk tactics, experts discuss logistics”   Tactics/Strategy/Team   General Operative Management for abd, prep knee to chin for ext, prep entire ext and 1 unaffect lower ext neck, prep entire chest   Lethal triad of hypothermia, coagulopathy, and acidosis   always choose the repair option which fails best   figure of eight, first bite to lift the tissue, 2nd bite to get the bleeder         (Peterson J Traum Volume 58(5).May 2005.1078-1 81)   Do not use bovine fibrin glue anymore, it may sensitize to ATIII  

Relative Bradycardia

Bradycardia actually incredibly common and predicts bad outcome in some groups (J Trauma 2009;67:1051)   Bradycardia may be present very often in hypovolemic/hemorrhagic shock. There is a biphasic response, the first and the one we commonly think of is catecholamine surge with resulting tachycardia and increased card output. Later on, there is actually a cardiac vagal response resulting in bradycardia. This may be present in up to 1/3 of hypovolemic patients (BMJ 2004;328:451-453 (21 February))   bradycardia is more common than tachycardia in acute blood loss (9.McGee S, Abernathy WB, Simel DL. Is this patient hypovolemic? JAMA 1999; 281:1022–1029)Bezold-Jarisch     Bradycardia may be present very often in hypovolemic/hemorrhagic shock. There is a biphasic response, the first and the one we commonly think of is catecholamine surge with resulting tachycardia and increased card output. Later on, there is actually a cardiac vagal response resulting in bradycardia. This may be present in up to 1/3 of hypovolemic patients (BMJ 2004;328:451-453 (21 February))   ATLS HR/BP correlations with degree of shock are crap (Resus 2010;81:1142)   Additional articles about bradycardia during bleeding J Accid Emerg Med 1995;12:1 J Am Coll Surg 2003;196:679 J Trauma 1998;45:534 not being tachycardic actually portends a worse outcome in the setting of shock (J Trauma. 2011;71: 789–792)

Automated BPs are Inaccurate

they overestimate the BP until SBP > 110 this may be the root of the phenomena of insanely high BPs when pt’s first arrive J Trauma. 2003;55:860 –863.

CPR for Trauma

retrospective prehospital study. DNR if apneic and pulseless on arrival or asystolic or PEA with rate<40 (J AM Coll Surg 2004;198:227)   Another study shows prognosis in traumatic arrest is the same as medical (Crit Care Med 2007;35:2251)

Massive Transfusion Protocol

Rectal Exam

Reasons to Omit Digital Rectal Exam in Trauma Patients: No Fingers, No Rectum, No Useful Additional Information (J Trauma 2005;59(6):1314) Level I has only limited air elimination abilities (J Clin Anesthesia 1997;9:233) Study objective: Most injured patients taken by ambulance to hospital emergency departments do not require emergency surgery, yet most US trauma centers require a surgeon to be present on their arrival. If a clinical decision rule could be developed to accurately identify which injured patients require emergency operative intervention, then such “secondary triage” criteria could permit a trauma center to more efficiently use their surgeons’ time. Methods: We analyzed 7.5 years of data (8,289 consecutive trauma activations) in our prospectively maintained Level I trauma center registry. We used classification and regression tree analyses to generate clinical decision rules using standard out-of-hospital variables to identify emergency operative intervention (within 1 hour) by a general surgeon (for adults) or a pediatric surgeon (if _14 years). Results: Emergency operative intervention occurred in 3.0% of adults and 0.35% of children. For adults, summoning a surgeon for any one of 3 criteria (penetrating mechanism, systolic blood pressure _96 mm Hg, pulse rate _104 beats/min) could reduce surgeon calls by 51.2% while failing to identify emergency operative intervention in only 0.08% (rule sensitivity 97.2% and specificity 48.6%). For children, no rule at all (ie, never automatically summoning a surgeon) would fail to identify emergency operative intervention in only 0.35% of patients, and use of a single criterion (penetrating mechanism) would reduce surgeon calls by 96.2% while failing to identify emergency operative intervention in only 0.09% (rule sensitivity 75.0% and specificity 96.5%). Conclusion: We have derived simple decision rules for trauma centers that, if validated, could substantially reduce the need for routine surgeon presence on trauma patient arrival. These rules demonstrate low false-negative rates. [Ann Emerg Med. 2006;47:135-145.]   article discussing the evidence (Annals of EM 2006;47(5):405)

Damage Control

Scalea [19] has condensed the principles of damage control: only blood loss kills early; gastrointestinal injury causes problems later; everything takes longer than you think; an injury may be missed during hurried laparotomy in an unstable patient; hypothermia, acidosis, and coagulopathy lead to more of the same; the best setting for a critically ill patient is the intensive care unit. Damage control Review article by Feliciano   Low iCal at arrival is associated with bad outcome (J Trauma Volume 61(4), October 2006, pp 774-779)   Cochrane Database Syst Rev. 2004;(3):CD004173. MAIN RESULTS: There is a limited literature relating to this topic but none of the studies identified met the inclusion criteria for this review. REVIEWERS’ CONCLUSIONS: There is no clear evidence that ATLS training (or similar) impacts on the outcome for victims of trauma, although there is some evidence that educational initiatives improve knowledge of what to do in emergency situations. Further, there is no evidence that trauma management systems incorporating ATLS training impact positively on outcome. Future research should concentrate on the evaluation of trauma systems incorporating ATLS, both within hospitals and at the health system level, by using rigorous research designs.   Resus from Severe Hemorrhage (Crit Care Med 1996;24(2):12S) mention the Bickell Study (NEJM 1994;331:1105) delayed till operating room vs. immediate. give fluids when inducing or pericode Hypertonic Saline (Trauma Resus update Lancet 2004;363:1988)

HCT and Hb are the same

J Trauma, Volume 62(5).May 2007.1310-1312 HCT may be low or normal or sick patients (Journal of Trauma and Acute Care Surgery Volume 72(1), January 2012, p 54–60)

Helmets

Trauma & Motorcyclists (Injury 2007;38:1131) Pull helmet edges in

the lateral direction

What you can ligate

Nugget Approach to Bleeding

Journal of Emergency Medicine Volume 34, Issue 3, April 2008, Pages 319-320

how to properly apply direct pressure    

Interventional Radiology in Trauma

INJURY Volume 39, Issue 11, Pages 1229-1308 (November 2008)Interventional Radiology in Trauma Care Edited by S.J.A. Sclafani and I.D.S. Civil

Complications after Exploratory Laparotomy

in one study, very low (Journal of Trauma-Injury Infection & Critical Care: September 1996 – Volume 41 – Issue 3 – pp 509-513)

EM Traumatologists

Article in surgery literature

Indications for bullet removal

1. Just under the skin, and residing in a pressure area where the bullet is painful when the patient sits or lies down.
2. Visibly bulging beneath the skin and causing cosmetic distress.
3. In a joint space
4. In the globe of the eye.
5. In a vessel lumen causing ischaemia or with the risk of embolisation to the heart, lungs or peripheral vessles.
6. Impinging on a nerve or nerve root and causing pain.
7. Localised abscess formation (usually due to dirt or clothing fragments entrained by the bullet).
8. Required for forensic investigation and the patient and surgeon are in full agreement that the removal will not result in increased pain, suffering, complications or injury and both agree to the removal.
9. Documented elevated lead levels, usually in a child and occurring several months after injury (extremely rare)

Vasopressors

Vasopressors kill trauma patients, don’t do it (J Trauma 2008;64:9)

Balloon Pump

Balloon Pump to Stop Abd/Pelvis Bleeding (J Trauma 2010;68(4):942)   Assar AN, Zarins CK. Endovascular proximal control of ruptured abdominal aortic aneurysms: the internal aortic clamp. J Cardiovasc Surg (Torino). 2009;50:381–385. Mount Sinai Serials Bibliographic Links [Context Link] Gupta BK, Khaneja SC, Flores L, Eastlick L, Longmore W, Shaftan GW. The role of intra-aortic balloon occlusion in penetrating abdominal trauma. J Trauma. 1989;29:861–865. Ovid Full Text Mount Sinai Serials Request Permissions Bibliographic Links [Context Link] Karkos CD, Bruce IA, Lambert ME. Use of the intra-aortic balloon pump to stop gastrointestinal bleeding. Ann Emerg Med. 2001;38:328–331. Ovid Full Text Mount Sinai Serials Bibliographic Links [Context Link] Harma M, Harma M, Kunt AS, Andac MH, Demir N. Balloon occlusion of the descending aorta in the treatment of severe post-partum haemorrhage. Aust N Z J Obstet Gynaecol. 2004;44:170–171. Mount Sinai Serials Bibliographic Links [Context Link] Rieger J, Linsenmaier U, Euler E, Rock C, Pfeifer KJ. [Temporary balloon occlusion as therapy of uncontrollable arterial hemorrhage in multiple trauma patients]. Rofo. 1999;170:80–83. Mount Sinai Serials Bibliographic Links [Context Link]   10 F sheath 20-mm berenstein balloon introduced to 50 cm slowly inflate dwith saline until friction is felt against wall eventually placed in infrarenal aorta identify absent femoral pulses

5% Hypertonic as a Resus Fluid

Mikey likes it Journal of Trauma: Injury, Infection, and Critical Care 68(5), May 2010, pp 1172-1177

or my 1.3%

1 amp of 44.6 bicarb in 500 ml of NSmakes 550 of total volume=Na 121.6Cl 77Bicarb 44.6to extend to 1 literNa 217Cl 138.6 BiCarb 801.3% Saline solution

Intestinal Allis Clamps

can be used to close organs

Prognosis

We are very poor at predicting prognosis in the trauma ICU ((J Trauma. 2010;68: 1279–1288)

Isolated Episodes of Hypotension

Even a single drop < 105 SBP associated with severe injuries (J Trauma. 2010 Jun;68(6):1289-94; discussion 1294-1295.)

Delay to IR

each hour of delay is associated with an almost ~50% increase in mortality in a J trauma retropsective study ( J Trauma 2010;68:1296)

Tranexamic Acid

Massive Transfusion

Stopping Vessel Bleeding

use dead head from three way stopcock held in forceps (J Trauma 2010;69(2):466)

EMS Scene Time

The authors state: “In this study, we were unable to support the contention that shorter out-of-hospital times… improve survival among injured adults with field-based physiologic abnormality… Our findings are consistent with those of previous studies that similarly have failed to demonstrate a relationship between out-of-hospital time and outcome using different patient populations, trauma and EMS systems, regions, data sources, and confounders“ Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort Ann Emerg Med. 2010 Mar;55(3):235-246 from resus.me

ATLS Shock Classification Doesn’t Work

An excellent discussion section in this paper states: ‘it is clear that the ATLS classification of shock that associates increasing blood loss with an increasing heart rate, is too simplistic. In addition, blunt injury, which forms the majority of trauma in the UK, is usually a combination of haemorrhage and tissue injury and the classification fails to consider the effect of tissue injury‘ Testing the validity of the ATLS classification of hypovolaemic shock Resuscitation. 2010 Sep;81(9):1142-7 from resus.me Resuscitation Volume 82, Issue 5, May 2011, Pages 556-559 What will probably work better is a Base Deficit or Lactate based approach. Class I (BD <=2.0), Class II (BD 2-6), Class III (6-10), Class IV (BD >10) Crit Care 2012;17:R42

Vitals in the Elderly

normal vital signs are in no way reassuring in the elderly get scared when the SBP < 100 and/or HR > 90 (j trauma 2010;813)   Crystalloid >1500 ml of crystalloid assoc with increased risk of death after multivariate (The Journal of Trauma: Injury, Infection, and Critical Care Issue: Volume 70(2), February 2011, pp 398-400) Optimal emergency department SBP cutoff values for hypotension were 85 mm Hg for patients aged 18 to 35 years, 96 mm Hg for patients aged 36 to 64 years, and 117 mm Hg for elderly patients. (Arch Surg. 2011;146(7):865-869)

Steroids for Pneumonia

small rct from france shows reduced mortality for trauma patients given hydrocortisone for the outcome of HAP (JAMA. 2011;305(12):1201-1209)

Hypotensive Resuscitation

New RCT of OR management showed hypotensive resus is safe and may have mortality benefit (J Trauma 2011;70:652)

Blunt Traumatic Arrest

Can have tension pneumothorax with no clinical signs and then gain immediate ROSC (Emerg Med J-2009-Mistry-738-40)

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

(J Trauma 2011;71(6):1869)

FIRST Trial – HES for Pentrating Trauma

Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma)   Br J Anaesth. 2011 Nov;107(5):693-702

Helicopter vs. Ground Transport

(JAMA 2012;307(15):1602) chopper use assoc. with increased survival in major trauma. This was a retrospective propensity score analysis. and Prehospital Emerg Care 15(3):295-302, 2011.

Raptor Suites

Resuscitation with angiography, percutaneous techniques, and operative repair (Can J Surg 2011;54(5):E3)

Prophylactic Antibiotics for Penetrating Abdominal Trauma

EAST 2012 RECOMMENDATIONS Back to Top Level 1 1. A single preoperative dose of prophylactic antibiotics with broad-spectrum aerobic and anaerobic coverage should be administered to all patients sustaining penetrating abdominal wounds. 2. Prophylactic antibiotics should be continued for not more than 24 hours in the presence of a hollow viscus injury in the acutely injured patient. 3. Absence of a hollow viscus injury requires no further administration of antibiotics. Back to Top Level 2 1. There are no Level 2 recommendations. Back to Top Level 3 1. In patients admitted with hemorrhagic shock, the administered dose of antibiotics may be increased twofold or threefold and repeated after transfusion of every 10 units of blood until there is no further blood loss. 2. Aminoglycosides should be avoided because of suboptimal activity in patients with significant injuries if possible.

Prehospital Fluid Resuscitation in Trauma

Pts who got >500 ml, but were not hypotensive had increased mortality (Journal of Trauma and Acute Care Surgery . 74(5):1207–1214, May 2013.)