1. Introduction to Trauma Erik G. Van Eaton, MD Assistant Professor Department of Surgery Division of HMC Trauma Univ. of Washington Seattle, Washington Erik G. Van Eaton, MD Assistant Professor Department of Surgery Division of HMC Trauma Univ. of Washington Seattle, Washington

2. Presenter Disclosure Slide Erik G. Van Eaton, MD I’m a Trauma Surgeon Focused Decisive

3. Presenter Disclosure Slide Erik G. Van Eaton, MD I’m a Trauma Surgeon Focused Decisive Sometimes Wrong Never in Doubt

4. Presenter Disclosure Slide Erik G. Van Eaton, MD I’m a Trauma Surgeon Focused Decisive Sometimes Wrong Never in Doubt Just a Little Bit Mean – Don’t Take it Personally

5. Presenter Disclosure Slide Oh – and most of these slides are copied directly from ATLS ® American College of Surgeons ♦ Committee on Trauma

6. Trauma Fundamentals Stable vs Unstable Blunt vs Penetrating Operative vs Non-Operative Stable vs Unstable Blunt vs Penetrating Operative vs Non-Operative

7. Trauma Fundamentals Stable vs Unstable –How do we define unstable? –What causes instability in trauma patients? –What initial tests can quickly help us? Stable vs Unstable –How do we define unstable? –What causes instability in trauma patients? –What initial tests can quickly help us?

8. What is Unstable, in Trauma? Your thoughts?

9. The Unstable Trauma Patient Your thoughts? Shock = Unstable Your thoughts? Shock = Unstable

10. Case Scenario 28-year-old woman in car crash Pulse: 126; BP 96/70; RR: 28 Confused and anxious Is this patient in shock? What type? What should be done? 28-year-old woman in car crash Pulse: 126; BP 96/70; RR: 28 Confused and anxious Is this patient in shock? What type? What should be done?

11. Case Scenario 21-year-old man with gunshot to torso Pulse: 118; BP 158/89; RR 15 Alert, oriented, skin warm & dry Is this patient in shock? What type? What should be done? 21-year-old man with gunshot to torso Pulse: 118; BP 158/89; RR 15 Alert, oriented, skin warm & dry Is this patient in shock? What type? What should be done?

12. Today You Will Learn To Define shock Recognize the shock state Determine the cause of shock in trauma Control hemorrhage early Make resuscitation plan & monitor response Recognize some trauma is operative & some is non-operative Define shock Recognize the shock state Determine the cause of shock in trauma Control hemorrhage early Make resuscitation plan & monitor response Recognize some trauma is operative & some is non-operative

13. What is Shock? Cell death Inadequate oxygen delivery Catecholamines and other responses Anaerobic metabolism Cellular dysfunction Generalized State of Hypoperfusion

14. How Do I Recognize Shock? Look for poor perfusion –Altered mentation –Cold, clammy skin –Tachycardia –Tachypnea –Hypotension –Poor urine output Look for poor perfusion –Altered mentation –Cold, clammy skin –Tachycardia –Tachypnea –Hypotension –Poor urine output

15. My Patient is in Shock – Why? Your thoughts?

16. My Patient is in Shock – Why? Quick history: –Mechanism? –A.M.P.L.E. –Response to field interventions Pick from two categories… Quick history: –Mechanism? –A.M.P.L.E. –Response to field interventions Pick from two categories…

17. Trauma: Simplify Shock Causes Hypovolemic –Blood loss –Fluid loss Hypovolemic –Blood loss –Fluid loss Nonhemorrhagic –Tension pneumothorax –Cardiac tamponade –Cardiogenic –Septic –Neurogenic

18. Take Home Point #1 Trauma patients presenting in shock are bleeding until proven otherwise Get a surgeon involved right away Trauma patients presenting in shock are bleeding until proven otherwise Get a surgeon involved right away

19. Case Scenario 28-year-old woman in car crash Pulse: 126; BP 96/70; RR: 28 Confused and anxious Is this patient in shock? What type? What should be done? 28-year-old woman in car crash Pulse: 126; BP 96/70; RR: 28 Confused and anxious Is this patient in shock? What type? What should be done?

20. Case Scenario 28-year-old woman in car crash Pulse: 126; BP 96/70; RR: 28 Confused and anxious Is this patient in shock? - YES What type? - Hypovolemic What should be done? 28-year-old woman in car crash Pulse: 126; BP 96/70; RR: 28 Confused and anxious Is this patient in shock? - YES What type? - Hypovolemic What should be done?

21. Repeat After Me … A – Airway B – Breathing C – Circulation D – Disability E – Exposure IV, Oxygen, Monitors A – Airway B – Breathing C – Circulation D – Disability E – Exposure IV, Oxygen, Monitors

22. Always Look For Bleeding Why is my trauma patient in shock? –In the vast majority of trauma patients, shock is due to blood loss. Why is my trauma patient in shock? –In the vast majority of trauma patients, shock is due to blood loss.

23. The Primary Survey ABCDE Look for blood loss –“Blood on the floor, PLUS four more.” Diagnostic adjuncts –AP Chest X-ray –AP Pelvis X-ray –FAST/DPL ABCDE Look for blood loss –“Blood on the floor, PLUS four more.” Diagnostic adjuncts –AP Chest X-ray –AP Pelvis X-ray –FAST/DPL

24. The Primary Survey ABCDE Look for blood loss –“Blood on the floor, PLUS four more.” Diagnostic adjuncts –AP Chest X-ray –AP Pelvis X-ray –FAST/DPL ABCDE Look for blood loss –“Blood on the floor, PLUS four more.” Diagnostic adjuncts –AP Chest X-ray –AP Pelvis X-ray –FAST/DPL

25. The Primary Survey ABCDE Look for blood loss –“Blood on the floor, PLUS four more.” Diagnostic adjuncts –AP Chest X-ray –AP Pelvis X-ray –FAST/DPL ABCDE Look for blood loss –“Blood on the floor, PLUS four more.” Diagnostic adjuncts –AP Chest X-ray –AP Pelvis X-ray –FAST/DPL

26. The Primary Survey ABCDE Look for blood loss –“Blood on the floor, PLUS four more.” Diagnostic adjuncts –AP Chest X-ray –AP Pelvis X-ray –FAST/DPL ABCDE Look for blood loss –“Blood on the floor, PLUS four more.” Diagnostic adjuncts –AP Chest X-ray –AP Pelvis X-ray –FAST/DPL

27. The Primary Survey ABCDE Look for blood loss –“Blood on the floor, PLUS four more.” Diagnostic adjuncts –AP Chest X-ray –AP Pelvis X-ray –FAST/DPL ABCDE Look for blood loss –“Blood on the floor, PLUS four more.” Diagnostic adjuncts –AP Chest X-ray –AP Pelvis X-ray –FAST/DPL

28. Take Home Point #2 Bleeding can sometimes be hard to find If your patient is unstable, keep reevaluating for sites of blood loss Bleeding can sometimes be hard to find If your patient is unstable, keep reevaluating for sites of blood loss

29. Take Home Point #2 Bleeding can sometimes be hard to find If your patient is unstable, keep reevaluating for sites of blood loss Blood on the floor, plus FOUR more Sometimes the OR is the best place to figure it out Bleeding can sometimes be hard to find If your patient is unstable, keep reevaluating for sites of blood loss Blood on the floor, plus FOUR more Sometimes the OR is the best place to figure it out

30. Interventions Direct pressure / tourniquet STOP the bleeding! Reduce pelvic volume Angio- embolization Splint fractures Operation What can I do about it?

31. Who Goes Directly to OR?

32. Penetrating trauma –Unstable with any trunk wound –Stable with peritoneal violation –Stable with other criteria (e.g. limb arterial) Blunt trauma –Unstable & bleeding in belly or chest –Stable with injury to gut –Specific injuries (e.g. head bleed & shift) Penetrating trauma –Unstable with any trunk wound –Stable with peritoneal violation –Stable with other criteria (e.g. limb arterial) Blunt trauma –Unstable & bleeding in belly or chest –Stable with injury to gut –Specific injuries (e.g. head bleed & shift)

33. Take Home Point #3 Look for immediate indications for OR and get a surgeon involved The rest of the work up can continue during & after OR Look for immediate indications for OR and get a surgeon involved The rest of the work up can continue during & after OR

34. Interventions Fluid resuscitation –Vascular access –Type of fluid –Volume of fluid Fluid resuscitation –Vascular access –Type of fluid –Volume of fluid

35. ● Slightly anxious ● Normal blood pressure ● Heart rate < 100 / min ● Respirations 14-20 / min ● Urinary output 30 mL / hour 750 mL BVL (15%) Crystalloid Class I Hemorrhage

36. ● Anxious ● Normal blood pressure ● Heart rate > 100 / min ● Decreased pulse pressure ● Respirations 20-30 / min ● Urinary output 20-30 mL / hour 750-1500 mL BVL (15-30%) Crystalloid, ? blood Class II Hemorrhage

37. ● Confused, anxious ● Decreased blood pressure ● Heart rate > 120 / min ● Decreased pulse pressure ● Respirations 30-40 / min ● Urinary output 5-15 mL / hour 1500-2000 mL BVL (30-40%) Crystalloid, blood components, operation Class III Hemorrhage

38. ● Confused, lethargic ● Hypotension ● Heart rate > 140 / min ● Decreased pulse pressure ● Respirations >35 / min ● Urinary output negligible >2000 mL BVL (>40%) !! Definitive control, blood components Class IV Hemorrhage

39. Take Home Point #4 Always start with crystalloid boluses, but in Class IV hemorrhagic shock, give blood too – don’t wait.

40. Interventions Fluid resuscitation –Vascular access –Type of fluid –Volume of fluid Monitor response Prevent hypothermia! Fluid resuscitation –Vascular access –Type of fluid –Volume of fluid Monitor response Prevent hypothermia!

41. How to Monitor Response Look for improved organ function –Warm skin, brisk cap refill –Increased urine output –Improved vital signs –Improved mentation Look for improved organ function –Warm skin, brisk cap refill –Increased urine output –Improved vital signs –Improved mentation

42. How to Monitor Response Patients fit into three categories: –Rapid responder –Transient responder –Nonresponder Patients fit into three categories: –Rapid responder –Transient responder –Nonresponder

43. How to Monitor Response Patients fit into three categories: –Rapid responder –Transient responder –Nonresponder Patients fit into three categories: –Rapid responder –Transient responder –Nonresponder

44. How to Monitor Response Patients fit into three categories: –Rapid responder –Transient responder –Nonresponder Patients fit into three categories: –Rapid responder –Transient responder –Nonresponder

45. How to Monitor Response Patients fit into three categories: –Rapid responder –Transient responder –Nonresponder Patients fit into three categories: –Rapid responder –Transient responder –Nonresponder

46. Take Home Point #5 Transient responders & nonresponders are still bleeding They usually need an intervention – NOT a CT scan Transient responders & nonresponders are still bleeding They usually need an intervention – NOT a CT scan

47. Operative & Non-operative Penetrating trauma –Not all stab wounds need the OR –Chest wounds: tube thoracostomy first –Neck wounds have special protocols Blunt trauma –Stable & solid organ injury only: ICU –Pelvis & retroperitoneal bleeds: Angio –Extremity bleeds: Reduce fractures! Penetrating trauma –Not all stab wounds need the OR –Chest wounds: tube thoracostomy first –Neck wounds have special protocols Blunt trauma –Stable & solid organ injury only: ICU –Pelvis & retroperitoneal bleeds: Angio –Extremity bleeds: Reduce fractures!

48. ● Age extremes ● Athletes ● Pregnancy ● Medications ● Pacemaker Patient Factors Pitfalls

49. ● Equating BP with cardiac output ● Misleading hemoglobin and hematocrit levels ● Equating BP with cardiac output ● Misleading hemoglobin and hematocrit levels Pitfalls Errors in Shock Management Pitfalls

50. ● Hypothermia ● Early coagulopathy ● Hypothermia ● Early coagulopathy Pitfalls Complications of the Shock State Pitfalls

51. Questions?

52. ● Shock is inadequate organ perfusion and tissue oxygenation. ● Hypovolemia is the cause of shock in most trauma patients. ● Patients may present with mild to severe shock. Summary

53. ● Conduct a rapid initial assessment and resuscitation: ABCDE ● Give blood early in Class IV (Class III?) shock. ● Determine cause of shock. ● Stop the bleeding. ● Reevaluate. Summary

54. ● Look for indications to go to OR. ● Some cases are non-operative, but need angiography or ICU monitoring. ● Reevaluate! Summary