Trauma resuscitation
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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)


Trauma resuscitation

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


Pre hospital care

Pre-hospital care


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


Which way for the airway

Which way for the Airway?


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 <750750-15001500-2000 >2000

HR<100 >100 >120 >140

BPNLNLLOWLOW

UO >3020 - 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


Too much fluid

Too much fluid?


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


What is wrong with this cxr

What is wrong with this CXR?


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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