Trauma, severe injury. dr. Péter Kanizsai Semmelweis University, Dept. of Anaesthesia and Intensive Care Division of Oxyology and Emergency Medicine
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1 Trauma, severe injury dr. Péter Kanizsai Semmelweis University, Dept. of Anaesthesia and Intensive Care Division of Oxyology and Emergency Medicine
2 What is severe injury? Severe injury : a significant acquired brain injury, paraplegia, quadriplegia, amputation of a limb or burns to more that 50 percent of the body; or any other injury specified by the regulations for the purposes of this definition The following injuries (have been prescribed by regulation) as severe injuries: permanent blindness burns to not more than 50 percent of the body that cause severe disfigurement and comprise of full thickness burns: to the head, neck, arms or lower legs; or that result in severe difficulties in performing mobility, communication and self care tasks a brachial plexus injury that results in the loss of the use of a limb
3 How can we tell it is severe? Revised Trauma Score (RTS) Injury Severity Score (ISS) Coded Value GCS SBP (mm Hg) RR (breaths /min) < 50 < > > Glasgow Coma Scale (GCS) Systolic Blood Pressure (SBP) Respiratory Rate (RR) Coded Value > > RTS = GCS SBP RR
4 TRISS Trauma Score - Injury Severity Score : TRISS TRISS determines the probability of survival (Ps) of a patient from the ISS and RTS using the following formulae: Where 'b' is calculated from:
5 Trauma facts Epidemiology Leading cause of death in the first 4 decades 150,000 deaths annually in the US mortality 17 % in Europe Permanent disability 3 times the mortality rate Trauma related dollar costs exceed $400 billion annually
6
7 Trimodal (classic) death distribution Courtesy of dr. Z. Pető, University of Szeged
8 Bimodal death distribution
9 The Nebraska experience, 1976
10 Organizational aspects Improved resuscitation/critical care A advanced T trauma L life S - support
11 The ATLS Concept ABCDE approach to evaluation and treatment Treat greatest threat to life first Definitive diagnosis not immediately important Time is of essence Do no further harm Good recordkeeping is of paramonunt!
12 ATLS Concept Airway with c-spine protection Breathing / ventilation / oxygenation Circulation: stop the bleeding! Disability / neurological status Expose / Environment / body temperature
13 The trauma team An effective trauma system needs the teamwork of EMS, emergency medicine, trauma surgery, and surgery subspecialists Trauma roles Trauma captain Interventionalists Nurses Recorder
14 Trauma Team
15 Initial Assessment / Management Injury Transfer Primary Survey Resuscitation Re-evaluation Adjuncts Detailed Secondary Survey Optimize patient status Re-evaluation Adjuncts Courtesy of dr. Z. Pető, University of Szeged
16 Initial assessment organizational aspects (time dependent team work) always seek info on the mechanism of injury any death in the same compartment high velocity collision ejection vital signs prioritize primary survey and initial stabilization are simultaneous activities!
17 Quick Assessment What is a quick, simple way to assess a patient in 10 seconds? Identify yourself Ask the patient his or her name Ask the patient what happened Courtesy of dr. Z. Pető, University of Szeged
18 Methods of primary survey Physical examination look, listen and feel BP HR SpO 2 CRT temperature PoC techniques: ABG analysis FAST CXR, C-spine Imaging CT MR
19 Focused Assessment with Sonography in Trauma FAST
20 FAST
21 Systematic approach A airways with cervical spine protection First you'll need to judge if the airway patent? Have the patient speak to you to establish patency and to evaluate for voice change and stridor Is there evidence of pooling secretions or cyanosis? If airway is intact: look for problems which may cause the patient to lose that airway in the near future. facial injury causing obstruction or bleeding laryngeal fractures expanding hematomas GCS of 9 or less requires intubation
22 Systematic approach B - breathing Inspect: look for cyanosis, JVD (tension pneumothorax or cardiac tamponade) symmetric movement of the chest (flail chest) accessory muscle use (tension pneumothorax) open chest wounds (open pneumothroax). Ausculate: listen for stridor (upper airway injury), lung breath sounds (pneumo or hemothorax) Percuss: feel for: hyper-resonance (pneumothorax) dullness (hemothorax, FAST) subcutaneous emphysema (airway injury) paradoxical movements (flail chest) crepitation & point tendnerness(rib fractures) bruising (pulmonary contusion).
23 Systematic approach C- Circulation Hemorrhage should be assumed in any hypotensive trauma patient Rapid assessment of hemodynamic status Level of consciousness Skin color Pulses in four extremities Blood pressure and pulse pressure
24 Systematic approach Circulation Interventions Cardiac monitor Apply pressure to sites of external hemorrhage Establish IV access 2 large bore IVs Central lines if indicated Cardiac tamponade decompression if indicated (FAST) Volume resuscitation Have blood ready if needed Level One infusers available Foley catheter to monitor resuscitation
25 Systematic approach C - circulation Feel for pulses. as a rule of thumb: if a radial pulse is palpable, it suggests a systolic blood pressure of at least 80 mm Hg. if the femoral or carotid are palpable, these suggest a systolic blood pressure of at least 60 mm Hg. Most patients will have a tachycardic response. exceptions: Neurogenic shock to sympathetic cord disruption Beta blockade, Calcium channel blockade Elderly Children and young adults Conditioned athletes start with a lower basal level.
26 Systematic approach C - circulation ATLS Classification of hemorrhagic shock Heart Rate Blood Pressure Findings Blood Loss Treatment Class I Normalfast Normal <15% Normal Saline Class II Normalfast Normallow Narrowed Pulse Pressure 15-30% Normal Saline Class III Fast Low Altered Mentation 30-40% NS + Blood Class IV Fast Low Obtunded >40% NS + Blood
27 Systematic approach D - disability Quick assessment of mental status via the AVPU scale: Alert - a fully awake patient. Voice - the patient responds when verbally addressed. Response to voice can be verbal, motor, or with eyes. Pain - the patient makes a response on any of the three component measures only when pain stimulus is delivered. Unresponsive - If the patient does not give any eye, voice or motor response to voice or painful stimuli. Perform a gross motor/sensory examination to determine if CNS is intact. Assess pupils for size, symmetry and reactivity. The Glascow Coma Score (GCS) evaluates mental status via assessment of eye opening, motor response, verbal response. (best possible :15, worst possible:3)
28 Disability Interventions Spinal cord injury High dose steroids if within 8 hours not recommended any more! ICP monitor- Neurosurgical consultation Elevated ICP Head of bed elevated Mannitol Hyperventilation Emergent decompression
29 Consider Early Transfer Use time before transfer for resuscitation! Do not delay transfer for diagnostic tests!
30 What is the secondary survey? The complete history and physical examination
31 Secondary survey 1. Head, eyes, ears, nose, and throat (HEENT) a. Assess for evidence of a basilar skull fracture by identifying the presence of Battle s sign (ecchymosis over the mastoid), raccoon eyes (ecchymosis around the eyes) or hemotympanum (blood behind the eardrum) Look for a cerebrospinal fluid (CSF) leak :rhinorrhea or otorrhea. b. Assess for depressed skull fractures by careful palpation. Do not fiddle with foreign bodies and bone fragments! c. Assess for facial injury and stability by palpating the facial bones. Severe fractures carry the risk of airway occlusion! Malocclusion of the teeth may indicate a mandible fracture. d. Look for lacerations that will require repair. Scalp lacerations can bleed vigorously. e. Determine visual acuity and assess pupillary size and function. f. Examine the nasal septum for a hematoma!
32 Secondary survey 2. Cervical spine/neck a. Palpate the cervical spine and identify areas of tenderness, swelling or step-off deformity. b. Look for penetrating injuries within the neck. c. Evaluate for subcutaneous emphysema, which may be associated with laryngotracheal injury or pneumothorax. 3. Chest a. Palpate the sternum, clavicles, and ribs for tenderness or crepitus. The presence of subcutaneous emphysema suggests an underlying pneumothorax. b. Look for bruising or deformity to suggest an injury to the underlying lung
33
34 Secondary survey 4. Abdomen a. Assess for any distention, tenderness, rebound or guarding. Watch for injuries to the liver and spleen. b. Flank ecchymosis may suggest a retroperitoneal bleed. c. The presence of a seat belt sign is correlated with an eight-fold higher relative risk of intraperitoneal injury d. Reliable assessment of the abdomen may be compromised (altered mental status, intoxication with alcohol or illicit drugs, or the presence of painful distracting injuries. 5. Back a. Log roll the patient with assistance while maintaining spinal alignment. Palpate the entire spine for any spinous process tenderness. b. Assess for hidden wounds in the axilla, under the cervical collar, and in the gluteal region.
35
36 Secondary survey 6. Pelvis a. In order to assess the stability of the pelvis gently employed anterior posterior compression of the anterior superior iliac spines, lateral compression of iliac crests, and cranial caudal distraction of opposite iliac crests. This should be performed one time only! b. Palpate the symphysis pubis for pain, crepitus, or widening. c. Pelvic fractures can be responsible for as much as 2-4 L of occult blood loss. 7. Perineum a. Evaluate the perineum for ecchymosis (pelvic fracture or urethral disruption.) 8. Urethra a. Look for blood at the urethral meatus to assess for possible urethral disruption before placing a urinary catheter.
37 Always inspect the back!
38
39 Secondary survey 9. Extremity examination a. Re-check the vascular status of each extremity, including pulses, color, capillary refill, and temperature. b. Inspect every inch, palpate every bone, and check the range of motion of all joints. Assess for deformity, crepitus, tenderness, swelling, and lacerations. c. Unstable fractures or those associated with neurovascular compromise should be reduced immediately. (hemostasis, preventing further injury, and enhancing patient comfort). 10. Neurologic a. At this time, a complete neurologic examination should be done: - repeat GCS score - reevaluation of the pupils - a cranial nerve examination - a complete sensory and motor examination - testing of the deep tendon reflexes - assessment of the response to plantar stimulation.
40 Airway management Aim: secure and permanent airway intubation surgical
41
42 Why do patients die despite all our efforts? What causes delayed trauma mortality?
43 Infection Complications Frequent COD in pts who survive longer than 3 days. Immune system is frequently depressed because of physiological response or treatment Accidents take place in dirty environment &id=10&rnd=
44 Acute Respiratory Distress Inflammatory syndrome-disrupts the alveolarcapillary membrane The permeability increases and proteins/fluid shift into the interstitial space A cascading failure begins that eventually leads to alveolar collapse &id=10&rnd=
45 Systemic Inflammatory Response Inflammation is a normal defensive response to insult/injury Creates a lethal microenvironment Vascular system shunts elements to area Leukocytes Plasma proteins platelets &id=10&rnd=
46 Systemic Inflammatory Response Local inflammation is generally self limiting (8-10 days) Systemic Organs remote from insult show signs Temperature abnormalities Tachycardia Ventilation abnormalities &id=10&rnd=
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48
49 Multi Organ Dysfunction Syndrome 7%-15% of critically ill patients suffer failure of at least two organ systems Failure of three or more organ systems leads to a 90%-95% mortality rate Trauma patients are very susceptible to Prolonged circulatory shock Tissue hypoxemia Infection &id=10&rnd=
50 MODS Either primary or secondary Results from acute immune and inflammatory response Chemistry is complicated The immune system turns on normal cells and destroys them &id=10&rnd=
51 Myoglobinuria Trauma causes increased breakdown of skeletal muscles the muscle releases myoglobin and potassium myoglobin is a large molecule that blocks the renal tubules kidney failure &id=10&rnd=
52 DIC Initially hypercoagulation leading to organ ischemia. Simultaneous micro vascular hemorrhage and clotting Clotting agents are consumed faster than created Most likely results from damage to the endothelium Results in uncontrolled bleeding additional to the blood loss due to the initial insult &id=10&rnd=
53 All the above will lead to HYPOVOLAEMIC SHOCK!
54 What is shock? Generalized State of Hypoperfusion Inadequate oxygen delivery Catecholamines and other responses Anaerobic metabolism Cellular dysfunction Cell death Courtesy of dr. Z. Pető, University of Szeged
55 Signs of shock Alteration in level of consciousness, anxiety Cold, diaphoretic skin Tachycardia Tachypnea, shallow respirations Hypotension Decreased urinary output Courtesy of dr. Z. Pető, University of Szeged
56 Interventions Direct pressure / tourniquet Reduce pelvic volume STOP the bleeding! Operation Angioembolization Splint fractures Courtesy of dr. Z. Pető, University of Szeged
57 The IT clamp
58 Fluid resuscitation Vascular access? Type? Volume? Monitor response Prevent hypothermia!
59 Vascular access? F= ΔP x π x r 4 8η x l
60 Type? Volume? Aim is to restore circulation -team approach -no benefit of colloid over crystalloid -give 2 litres of crystalloid initially (N.S.) -blood sample for serology, clotting screen -to keep Hb>80 g/l cell saver techniques are required -2 units of 0 neg blood can be transfused in emergency -always try to transfuse fully compatible bloodaim to a PLT count > 75 G/l and TT < 1,5 -if 1-1,5 blood volume was repleted give FFP and PLT complex -keep calcium > 1,13 mm/l and fibrinogen > 1 g/l -prevent DIC -New guidelines suggest use of (1 unit of PBC, 1 unit of FFP and 1 unit of platelet)
61 General emergency remarks Time dependency: Golden hour (?) Not scientifically supported But it s a good rule of thumb Definitive care is the answer- not field care
62 General emergency remarks Allocation care is allocated to patient transfer only if unavoidable prioritize according to severity
63 General emergency remarks Integration multidisciplinary approach in trauma care there is no I, only we consultation and referral 24/7
64 Now let s go and operate! Fractures need mended! Save the patients life with quick and extended operations!
65 But what if patient is too old? patient is exsanguinated? patient is hypothermic? patient is haemodynamically unstable? etc..
66 A new paradigm Damage control
67 Definitive care vs. damage control early total care borderline era damage control
68 In a timely fashion Most patients are not ready for intervention Long operations will result in large fluid and heat loss Not all threatening injuries are real threat to life Surgeons need self control
69 Vicious circle in major torso trauma KC Sihler, LM Napolitano : Massive Transfusion New Insights Chest, 2009; 36
70 Damage control Choosing the right candidate - hypothermia: T<34 C acidosis ph < 7,2 lactate > 5 mmol/l coagulopathy SBP < 70 Hgmm Transfusion > 15 units ISS > 36
71 Practice of damage control
72 Practice of damage control
73 Priorities in the multiple injured victim Save life - Resuscitation, ATLS (advanced trauma life support) e.g. chest drain, amputation, laparotomy Save limb - Revascularization - Fasciotomy Save fracture - Debridement - Reposition, stabilization, alignement
74 Take home messages Trauma is best managed by a team approach Importance of ATLS A thorough primary and secondary survey is key to identify life threatening injuries Once a life threatening injury is discovered, intervention should not be delayed Disposition is determined by the patient s condition as well as available resources.
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