Trauma

1. Trauma • “Trauma” - expression comprising a spectrum of severity, from a little scratch to a multiply injured patient. Also surgical intervention. • Organism reacts to such an accidental event with a “standard” program in order to restore the physiologic state. • Normal wound healing consists of (1) vasoconstriction, (2) coagulation, (3) inflammation, and (4) tissue generation. Independent of the extent of the injury, the body will try to repair itself by this sequence of events. Klinika Chirurgii Urazowej Paweł Grala

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3. Trimodal distribution of traumatic death Klinika Chirurgii Urazowej Paweł Grala

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6. High yield facts in trauma • „Golden hour” of trauma – immediately follows trauma: rapid assesement, diagnosis assesement, diagnosis and stabilization • Prehospital – control airway, external hemorrhage, rapid transport • AMPLE history • Primary survey: initial assesement and resuscitation of vital functions, prioritization (based on ABCDEFG) Klinika Chirurgii Urazowej Paweł Grala

7. Shock • Inadequate organ perfusion and tissue oxygenation – clinical and laboraratory appreciation • Cause: hypovolemia, cardiac failure (myocardial contusion), sepsis (early uncommon), CNS failure (loss of vasomotor sympathetic tone in spinal cord inj.: no tachycardia or cutaneous vasoconstriction), mechanical chest problems • Patophysiology – compensatory circulatory responses: vasoconstriction (cutaneous, muscular, visceral), preservation of BF to: kidneys, heart, brain, ↑HR, ↑DBP, ↓SBP (PP), tissue hypoperfusion and hypoxia → inadequate energy production → cellular swelling (lost integrity of cell membrane and electrical gradient), lactic acid → metabolic acidosis → cellular death → DEATH revascularisation → MODS → MOF → late DEATH Klinika Chirurgii Urazowej Paweł Grala

8. Shock – estimation of blood loss and need for fluid replacement (ACS) Klinika Chirurgii Urazowej Paweł Grala

9. Alghevar scheme • Quantification of shock: SBP / HR • >1 no or minor clinical symptoms • <1major shock Klinika Chirurgii Urazowej Paweł Grala

10. Small bowel „calamari-like”circumferential wall thickening andincreased contrast enhancement of the entire small bowel - diffuse edematous nonnecrotic injury Klinika Chirurgii Urazowej Paweł Grala

11. Management of shock • Goal – restoration of cellular perfusion • Standard: volume restoration - venous catheterization, CVL to monitor CVP, warmed Ringers Lactate (1L/3min), crossmatched FFP, RBC (possible 0 neg. for ♂ 0 pos.), no catecholamines or NaHCO3 • Surgical decisionmaking: rapid and stable response – stop fluids and blood transient response – continue fluid therapy, detemnine the need for surgery no response – immediate surgery • Errors and complications: no glucose solutions – ↑ of serum glucose → ↑ UA (false interpretation), less effective limit normal saline → dilutional acidosis colloids are good volume expanders with intact capillary membranes; in shock ↑ interstitial oedema; dextran and hydroxyethyl starch interfere with platelet function if over 1L exclude tension pneumothorax Klinika Chirurgii Urazowej Paweł Grala

12. Trousers and belts limit access to the abdomen and perineum and can cause compartment syndrome, particularly in hypotensive patients. Double-layered inflatable suits which, when inflated, exert pressure on the lower part of the wearer's body. The suits are used to improve or stabilize the circulatory state, i.e., to prevent hypotension, control hemorrhage, stabilise fractures and regulate blood pressure. The suits are also used by pilots under positive acceleration Klinika Chirurgii Urazowej Paweł Grala

13. Management of shocknew trends in therapy (permissive hypotension, purposfull hypotension, fluid restriction, selective minimal resuscitation) • Natural compensation for BL with SBP ±80 (maintenance of cerebral and renal perfusion) – post traumatic hypotension as protective response caused by neurologic, hormonal, humeral cytokines. • ↑ SBP prior to operative control of bleeding → repeated rebleeding – „pop a clot phenomenon” (↓platelets and clotting factors with each alliquot of BL) – cyclic hyper-resuscitation → abd compartment syndrome, renal failure, coagulopathy, respiratory insufficiency – death or longer ICU stays • No fluid resuscitation if peripheral pulses present, venous lines placed not started, if no peripheral pulse – start fluid in aliquot of 25 ml, until pulse present → stop fluid • Animal studies, prehospital resuscitation trauma trials, apply same principles to similar patophysiological groups (contained abd. aortic aneurysm, pulmonary contusion, bleeding ulcer, widend postraumatic mediastinum = postraumatic hypovolemia). Klinika Chirurgii Urazowej Paweł Grala

14. Immunolgy of trauma SIRS - systemic inflammatory response syndrome - counteracted by anti-inflammation (CARS - compensatory anti-inflammatory response syndrome). If both circumstances exist together - MARS (mixed antagonist response syndrome). All these syndromes can eventually lead to MODS (multiple organ dysfunction syndrome). Klinika Chirurgii Urazowej Paweł Grala

15. Immunolgy of trauma • SIRS, CARS, MARS, MODSCHAOS(cardiovascular shock, homeostasis, apoptosis, organ dysfunction, immune suppression) • Local Immune Response - reaction to the local trauma. Humoral and cellular immune mediators are locally activated in order to restore or minimize subsequent damage. Damaged tissue is degraded and tissue generation is stimulated. Furthermore, mechanisms to clear pathogens, neoplastic cells and antigens are activated. Concomitantly, anti-inflammatory mediators are released to ensure that an overwhelming proinflammatory response does not cause any negative side effects. • Initial Systemic Immune Response - local immune response is not able to control the initial damage, some of the mediators are released in the systemic circulation, attracting and activating macrophages, thrombocytes, coagulation factors, etc. that oppose the damage more vigorously. This process continues until the wound or wounds have healed and homeostasis has been restored. Klinika Chirurgii Urazowej Paweł Grala

16. Immunolgy of trauma • Exacerbating Systemic Inflammation – if homeostasis cannot be acheieved. SIRS  progressive endothelial dysfunction  ↑ microvascular permeability with transudation into the organs + microthrombi develop obstructing the microcirculation  local ischemia. Reperfusion of these local ischemic areas  reperfusion injury (O2 delivered into ischemic areaineffective anaerobic metabolismO radicalsactivation of inflamation and direct tissue injury) Dysregulation of vasodilatory and vasoconstrictory mechanisms  prominent vasodilatation with worsening of transudation and local ischemia Loss of organ function develops. If occurs in several organs  MODS (Rubor, Calor, Tumor, Dolor, Functio laesa). • In 50–80% of cases MODS  MOF  death (SOF-death rare, >4OF-mortality 100%) • Counterregulation of SIRS  anti-inflammatory mediators. If exaggerated  immunoparalysis occurs (CARS) diminished or no immunosurveillance  microorganisms can easily invade the body during this period  patients are prone to developing sepsis with subsequent septic shock Klinika Chirurgii Urazowej Paweł Grala

17. SIRS Systemic Inflammatory Response Syndrome Systemic response to nonspecific insults (infections, pancreatitis, trauma and burns) Symptoms: fever or hypothermia (>38, <36), tachycardia (HR > 90), tachypnea (RR >20, PaCO2 < 32mmHg), WBC (>12000, <4000) SIRS score (max. 4) 2  11,5 fold increase of death rate One hit model: initial insult (infectious or non-)  severe SIRS  MOF Two hit model: initial insult (less severe)  moderate SIRS  second insult severe SIRS MOF Klinika Chirurgii Urazowej Paweł Grala

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19. Systemic hypotermia • Body tempeature below 35° (mild >32°, moderate>30°, severe) • Elderly (impaired heat production and vasoconstriction), children (↑BSA/W, low energy deposits), alcohol abuse (vasodilatation) • Prevention: warmed intravenous fluids, judicious exposure of the patient, warm environment • Symptoms: decreased level of consciousness, cold, gray, cianotic skin, depression of respiration and heart function (tachybradycardia, tachybradypnea, hyperhyporeflexia), increased urinary output (cold diuresis), ECG (J wave – Osborne) • Complications: ventricular fibrillation, DIC, rhabdomyolysis, acute tubular necrosis • Treatment: 100% oxygen, prevent further heat loss, resuscitation (causious tdo announce death), rewarming – passive external r., active core r.(peritoneal and pleural lavage, hemodialysis, extracorporeal bypass). • Surface rewarming (heating blankets, heat pacs to groin and axilla, warm water immersion) can cause periferal vasodilatationcore temperature↓ (after-drop), relative hypovolemia (after-shock) Klinika Chirurgii Urazowej Paweł Grala

20. J-wave Klinika Chirurgii Urazowej Paweł Grala

21. Systemic hypotermia - patophysiology • ↓cardiac output • ↑cardiac irritability (<33°) – arrythmias • Hypocoagulability: ↓platelet aggregation, ↓activity of clotting cascade • loss of CNS regulation Klinika Chirurgii Urazowej Paweł Grala

22. Damage control • Staged operative interventions with periods of aggresive resuscitation • Indicated in patients at the limits of their physiologic reserve (in the OR)  require abrupt termination of procedure (initial, temporary control of surgical bleeding, contamination, ext.stabilisation of fractures), later  staged reconstruction • Lethal triad – hypothermia, coagulopathy, acidosis • Applied most often to abdominal trauma • High mortality Klinika Chirurgii Urazowej Paweł Grala

23. Damage control • Phase I – initial exploration rapid control of active hemorrhage and contamination (d.c. decision): packingsequential removal with surgical control of bleeding contaminationsuture closure, segmental stapled resection drainage (pancreas, liver) if coagulopathyreaproximation of tissue planes and repacking alternative abd. closure (Bogota bag, zipper) • Phase II – secondary resuscitation correction of hypotrermia, coagulopathy and acidosis  ICU possible abd. compartment syndrome: intraabd. Vascular insufficiency secondary to increased intraabd. pressure (abd. distention, ↓UO, ventilatory insufficiency with high peak inspiratory pressures, low CO secondary do decreased venous return, UB pressure >25cmH2O); surgical reexploration • Phase III – definitive operation planned reexploration and definitive repair of injuries (usually 48-72h after initial operation) conservative procedures (avoid risky reconstructions) preferable primary abd. closure Klinika Chirurgii Urazowej Paweł Grala

24. No conclusive evidence Decision upon personal experience and patients condition („too sick”) –occult hypoperfusion, risk of second hit Might be especially valuable in chest trauma or ARDS Relatively safe time window 5-10 days post trauma (cell recruitment, de-novo synthesis of proteins) Damage Control Orthopaedics Klinika Chirurgii Urazowej Paweł Grala

25. Polytraumatized patient • The general aims when managing a patient with fractures are haemorrhage control, prevention of exaggerated immune response removal of dead, contaminated and devitalized tissue (debridement) pain control, prevention or recognition and treatment of compartment syndrome once it has developed, prevention of ischaemia-reperfusion injury mobilization and facilitation of nursing care. • All these goals can be achieved by appropriate fracture stabilization, adequate and expedient debridement if necessary and fasciotomies where indicated. • The severity of the injuries sustained and the physiological status of the patient are the primary factors dictating which line of treatment is most appropriate for the polytrauma patient. Klinika Chirurgii Urazowej Paweł Grala

26. Damage control Klinika Chirurgii Urazowej Paweł Grala

27. Damage control Klinika Chirurgii Urazowej Paweł Grala

28. Damage control Klinika Chirurgii Urazowej Paweł Grala

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30. ABD DC Klinika Chirurgii Urazowej Paweł Grala

31. Orthopaedic DC Klinika Chirurgii Urazowej Paweł Grala

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33. Politrauma Uraz wielonarządowy to zespół obrażeń przekraczających w skali ISS 17 punktów, wiążący się z łańcuchem reakcji ogólnoustrojowych, które mogą prowadzić do zaburzeń funkcji lub niedomogi układów i narządów pierwotnie nieuszkodzonych. Klinika Chirurgii Urazowej Paweł Grala

34. Polytrauma A set of injuries with severity exceeding 17p. in ISS, associated with a chain of systemic reactions (inflammatory response with resultant immune compromise), that can adversely affect the function of initially uninjured organs and cause their disfunction or failure. Klinika Chirurgii Urazowej Paweł Grala

35. Polytraumamultiply injured patients (at least 2 body systems), severe isolated injury • on the scene: protection of the trauma scene triage with initial checkup (consciousness, respiration, fractures, bleeding), circumstances of the accident initial resuscitation and stabilization of fractures, control of external bleeding • in the ambulance: aggressive shock therapy analgesia anesthesia • in the ER: trauma team waiting simultaneous: resuscitation, diagnostics, monitoring (bladder catheter, central iv line, EKG) – acute period therapeutic decisions  emergency operations • hospital: more extensile diagnostics (CT, MRI, angiogram) continue fluid and blood transfusions (resuscitation) acute operations (intracranial lesions, spine frs with neurologic deficit, open fractures, long bone frs of the lower extremity, ophtalmologic trauma) – stabilization period secondary survey maxillofacial surgery, joint reconstructions – regeneration period (days 3-10) reconstruction surgery of bone and soft tissue tertiary survey Klinika Chirurgii Urazowej Paweł Grala

36. Early Total Care (ETC) • stabilization of major fractures within 24 h. • ‘‘acute period’’ (1—2 h) used for life-saving procedures, • ‘‘primary period’’ (day 1): management of open fractures and joints, stabilization of fractures and decompression of any compartment syndrome. • ‘‘secondary period’’(48—72 h) and ‘‘tertiary period’’ (>72): prolonged reconstructive surgical treatment (e.g. intra-articular fractures) • early major surgery has to be judged as too great a burden for polytraumatised patients. Primary procedures of greater than 6 h duration and major surgical procedures at days 2—4 should be avoided Klinika Chirurgii Urazowej Paweł Grala