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Trauma Resuscitation

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  1. Trauma Resuscitation Shelley Atkinson RN, MSN, ANP-BC, ACNP- BC

  2. 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.

  3. 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

  4. 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

  5. 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

  6. 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)

  7. ATLS • Assure that optimum care is provided and level of care does not deteriorate at any point during evaluation, resuscitation, or transfer process

  8. What is a Level One Trauma Center? A hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries.

  9. 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

  10. Level One Criteria Circulation • Systolic BP < 90mmHg or HR > 120 • Witnessed cardiac arrest from trauma • Uncontrolled/Arterial Bleeding with shock • Spinal/Neurogenic Shock

  11. 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)

  12. 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

  13. Level One Criteria Extremities • Multiple long bone fractures with shock • Mangled Extremity or Amputation • above wrist/ankle

  14. 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

  15. Level One Criteria Mechanism of Injury • Burns > 20% TBSA or burns combined with any other injury • Massive crush injury

  16. Pre-hospital care

  17. Initial Assessment Primary survey and resuscitation of vital functions are done simultaneously. A team approach

  18. Primary SurveyABCDEs • Airway with cervical spine protection • Breathing • Circulation with hemorrhage control • Disability: Neurologic status • Exposure/Environment

  19. 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

  20. Airway Obstruction Recognition Look Listen • Agitation/Obtunded • Decreased air movement • Retraction • Deformity • Airway debris • Normal speech- no obstruction • Noisy breathing – obstruction • Gurgle • Stridor • Hoarseness

  21. 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

  22. Which way for the Airway?

  23. 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

  24. 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

  25. Adjuncts to Primary Survey • ECG • CO2 detector • Pulse oximetry • Vital Signs

  26. 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

  27. 6 areas potential blood loss • Chest • Abdomen • Retroperitoneum • Pelvis • Long bones / Soft tissue • Scalp • …the ground

  28. 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

  29. Special Considerations In Diagnosis and Treatment of Shock • Age • Athletes • Pregnancy • Medications • Hypothermia • Pacemakers

  30. Vascular Access • 2 large-caliber, peripheral IVs • Central access • femoral • jugular • subclavian • Intraosseous • Obtain blood for crossmatch • Trauma panel – CBC, BMP, coags

  31. 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

  32. 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

  33. 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

  34. 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

  35. Too much fluid?

  36. Adequacy of ResuscitationClinical Variables • Mentation • Pulse, pulse pressure, BP • Urine output • Clot formation • Temperature • Lactate/base deficit

  37. Primary Survey - DisabilityNeurologic Evaluation • Baseline neurologic evaluation • GCS scoring • Pupillary response **Observe for neurologic deterioration

  38. 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)

  39. 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

  40. Spinal Cord Injury • Neurogenic Shock • Consider hemorrhage first… • Maintain spine immobilization • Fluid or no fluid? • Vasopressors

  41. 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

  42. Primary Survey - Exposure/Environmental Control • Completely undress the patient • Prevent hypothermia

  43. Deadly Triad • Hypothermia • Acidosis • Coagulopathy

  44. 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

  45. Re-warming • Aggressive therapy associated with significant decrease in: • blood loss • fluid requirements • organ failure • LOS in ICU • mortality rate

  46. Secondary Survey • Begins after ABCDE is completed • Resuscitative efforts underway • Each region of the body is completely examined

  47. Trauma imaging • Chest x-ray • Pelvis x-ray • FAST • focused assessment sonography in trauma • DPL (center-dependent) • diagnostic peritoneal lavage • CT scan • Traumagram