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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 .

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trauma resuscitation

Trauma Resuscitation

Shelley Atkinson RN, MSN, ANP-BC, ACNP- BC

objectives
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
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
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 distribution1
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
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)

slide7
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
What is a Level One Trauma Center?

A hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries.

level one criteria
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 criteria1
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 criteria2
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 criteria3
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 criteria4
Level One Criteria

Extremities

  • Multiple long bone fractures with shock
  • Mangled Extremity or Amputation
    • above wrist/ankle
level one criteria5
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 criteria6
Level One Criteria

Mechanism of Injury

  • Burns > 20% TBSA or burns combined with any other injury
  • Massive crush injury
initial assessment
Initial Assessment

Primary survey and resuscitation of vital functions are done simultaneously.

A team approach

primary survey abcdes
Primary SurveyABCDEs
  • 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
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
Airway Obstruction Recognition

Look

Listen

  • Agitation/Obtunded
  • Decreased air movement
  • Retraction
  • Deformity
  • Airway debris
  • Normal speech- no obstruction
  • Noisy breathing – obstruction
  • Gurgle
  • Stridor
  • Hoarseness
inadequate breathing
Inadequate Breathing

Look

Listen

  • Cyanosis
  • Change in Mental Status
  • Chest asymmetry
  • Tachypnea
  • Neck vein distention
  • Paralysis

Feel

  • Sub Q emphysema/chest wall crepitus
  • Tracheal deviation
  • “I can’t breathe”
  • “I am dying”
  • Stridor, wheezes
  • Decreased or absent breath sounds
rapid sequence intubation
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 intubation1
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
Adjuncts to Primary Survey
  • ECG
  • CO2 detector
  • Pulse oximetry
  • Vital Signs
primary survey circulation with hemorrhage control
Primary SurveyCirculation 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
6 areas potential blood loss
  • Chest
  • Abdomen
  • Retroperitoneum
  • Pelvis
  • Long bones / Soft tissue
  • Scalp
  • …the ground
trauma
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
Special Considerations In Diagnosis and Treatment of Shock
  • Age
  • Athletes
  • Pregnancy
  • Medications
  • Hypothermia
  • Pacemakers
vascular access
Vascular Access
  • 2 large-caliber, peripheral IVs
  • Central access
    • femoral
    • jugular
    • subclavian
  • Intraosseous
  • Obtain blood for crossmatch
  • Trauma panel – CBC, BMP, coags
hemorrhagic shock

Hemorrhagic Shock

Class I Class IIClass IIIClass IV

EBL <750 750-1500 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
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 hemorrhage1
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
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
adequacy of resuscitation clinical variables
Adequacy of ResuscitationClinical Variables
  • Mentation
  • Pulse, pulse pressure, BP
  • Urine output
  • Clot formation
  • Temperature
  • Lactate/base deficit
primary survey disability neurologic evaluation
Primary Survey - DisabilityNeurologic Evaluation
  • Baseline neurologic evaluation
  • GCS scoring
  • Pupillary response

**Observe for neurologic deterioration

head trauma
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 trauma1
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
Spinal Cord Injury
  • Neurogenic Shock
    • Consider hemorrhage first…
  • Maintain spine immobilization
  • Fluid or no fluid?
  • Vasopressors
septic shock
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
Primary Survey - Exposure/Environmental Control
  • Completely undress the patient
  • Prevent hypothermia
deadly triad
Deadly Triad
  • Hypothermia
  • Acidosis
  • Coagulopathy
hypothermia ht
Hypothermia (HT)
  • 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
Re-warming
  • Aggressive therapy associated with significant decrease in:
    • blood loss
    • fluid requirements
    • organ failure
    • LOS in ICU
    • mortality rate
secondary survey
Secondary Survey
  • Begins after ABCDE is completed
  • Resuscitative efforts underway
  • Each region of the body is completely examined
trauma imaging
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
Adjuncts Secondary Survey
  • Foley
  • NGT
  • ABG/lactate
    • If actively resuscitating
primary goal of initial operation for a trauma patient
Primary Goal of Initial Operation for a Trauma Patient

Damage Control

  • Hemorrhage Control
  • Contamination
case study 1
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
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
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
Question #3

True or False.

The patient’s need for airway protection and ventilation is due to unconsciousness.

1- True

2- False

question 4
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
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
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 11
Question #1

True or False.

This patient does not meet Level One Criteria.

1- True

2- False

question 21
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

question 31
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 41
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
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 12
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 22
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 32
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 42
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 51
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
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
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
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.
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