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Trauma: The Golden Hour Dennis Kim MD FRCS(C) Dennis Kim MD FRCS(C) General Surgery General Surgery Trauma & Critical Care POS Core Lecture Series Trauma.

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Presentation on theme: "Trauma: The Golden Hour Dennis Kim MD FRCS(C) Dennis Kim MD FRCS(C) General Surgery General Surgery Trauma & Critical Care POS Core Lecture Series Trauma."— Presentation transcript:

1 Trauma: The Golden Hour Dennis Kim MD FRCS(C) Dennis Kim MD FRCS(C) General Surgery General Surgery Trauma & Critical Care POS Core Lecture Series Trauma & Critical Care POS Core Lecture Series February February

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3 Objectives  concept of a golden hour  pathophysiology of shock in the trauma patient  resuscitation according to ATLS principles  overview  specifics

4 The Golden Hour  originated by R Adams Cowley  first sixty minutes after the occurrence of multi-system trauma  victim's chances of survival are greatest if they receive definitive care in the OR within the first hour after a severe injury

5 The Golden Hour  recently, the validity of the “golden hour” as a rigidly defined timeframe scrutinized  core principle of rapid intervention in trauma cases remains universally accepted

6 The Golden Hour  "There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable." - R Adams Cowley

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8 The Golden Hour Time and Trauma Outcomes  no convincing studies that time to treatment consistently leads to better outcome  outcome related to many factors including reduced time between injury and definitive care Ann Surg. 2003;237(2): Ann Surg. 2003;237(2):153-60

9 1. What is the most common cause of shock in the trauma patient?  septic B) cardiogenic C) hemorrhagic D) neurogenic

10 2. The most easily reversible cause of shock in the trauma patient is: A) hemorrhagic B) neurogenic C) tension pneumothorax D) cardiac tamponade

11 3. The most commonly injured solid intraabdominal organ in blunt trauma is: A) liver B) spleen C) kidney D) small bowel

12 4. The bloody vicious cycle of trauma refers to: A) bleeding, hypothermia, and acidosis B) bleeding, hyperthermia, acidosis C) transfusion, hypothermia, acidosis D) transfusion, hypothermia, alkalosis

13 5. Hemorrhagic shock is usually caused by bleeding into or from: A) abdomen B) pelvis C) chest D) head E) all of the above F) A,B,C

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17 The Golden Hour Shock Pathophysiology  inadequate organ perfusion and tissue oxygenation 3 factors determine: 1. oxygen content 2. oxygen delivery 3. distribution

18 The Golden Hour Shock Pathophysiology  prolonged hypoperfusion creates a vicious cycle of ischemia and shock 2 most important steps in managing shock: 1. recognition 2. treatment

19 The Golden Hour Rapid Resuscitation  restores circulating volume  improves oxygen delivery  prevents cellular ischemia and tissue necrosis  prevents onset of secondary cellular injury  prevents onset of MODS

20 The Golden Hour What should we be doing? Rapid assessment Resuscitation and stabilization Definitive management/Transfer ATLS

21 ATLS Overview The ATLS Concept  Primary Survey  Adjuncts  Secondary Survey  Definitive Care/Transfer

22 ATLS Overview The ATLS Concept  treat life threatening injuries as they are identified  assessment/diagnosis and resuscitation are simultaneous

23 ATLS Overview Primary Survey  AAirway  BBreathing  CCirculation  D(neurologic) Disability  EExposure / Environment  AMPLE

24 ATLS Overview Adjuncts  Urinary catheter  NG tube  Xrays

25 ATLS Overview Secondary Survey  Thorough “head to toe” assessment Definitive Care/Transfer

26 Deadly Dozen Lethal Six  airway obstruction  tension PTX  open PTX  flail chest  massive hemothorax  cardiac tamponade Hidden Six  pulmonary contusion  diaphragmatic tear/rupture  tracheobronchial injury  blunt cardiac injury  thoracic aortic disrupt  esophageal injury

27 ATLS Specifics A - airway (with C-spine protection) Preventable Deaths from Airway Problems  failure to recognize need for airway  inability to establish airway  failure to recognize incorrect placement  displacement of previously placed airway  failure to recognize need for ventilation  aspiration of gastric contents

28 Airway Algorithm

29 ATLS Specifics A - airway (with C-spine protection) Rapid Sequence Intubation (RSI)  preoxygenation  cricoid pressure  sedation (etomidate, midazolam)  succhinylcholine  orotracheal intubation  cuff inflation, confirmation of position  release of cricoid pressure

30 ATLS Specifics Alternative Airway Devices/Options  nasotracheal intubation  LMA / intubating LMA  Glide scope  fiberoptic intubation  surgical airway needlepercutaneousopen

31 ATLS Specifics Alternative Airway Devices/Options Alternative Airway Devices/Options

32 ATLS Specifics Surgical Airway Surgical Airway

33 ATLS Specifics A - airway (with C-spine protection) A - airway (with C-spine protection)  ATLS:  lateral C spine film  complete C spine series during secondary survey  Current practice:  in ER assume C spine injury  no C spine films in ER  CT scan of C spine with reconstructions

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35 ATLS Specifics A - airway (with C-spine protection) A - airway (with C-spine protection)  “Clearing” the C spine (multiple trauma patient)  rarely done in ER (except fully conscious, no distracting injury)  CT scan with reconstructions  Further studies  MRI  Flexion - Extension views

36 ATLS Specifics B – breathing  oxygenation  ventilation  monitoring clinical (auscultation) O 2 saturation EtCO 2 ABG’s

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38 ATLS Specifics C - circulation (shock management)  recognition and resuscitation from shock  post traumatic shock is hemorrhagic shock until proven otherwise

39 Shock Obstructive Tension pneumo Cardiac tamponade Nonobstructive Distributive Sepsis/SIRS Anaphylaxis Neurogenic Nondistributive Hypovolemic Hemorrhagic Third spacing Cardiogenic

40 ATLS Specifics C - circulation (shock management) Classification and mechanisms of shock  obstructive  tension pneumothorax  cardiac tamponade Tension pneumothorax is the most EASILY corrected cause of shock

41 ATLS Specifics C - circulation (shock management) Classification and mechanisms of shock  distributive  spinal cord injury  sepsis  anaphylaxis

42 ATLS Specifics C - circulation (shock management) Classification and mechanisms of shock  cardiogenic  myocardial contusion  valvular disruption  ischemic injury

43 ATLS Specifics C - circulation (shock management) Classification and mechanisms of shock  hypovolemic  blood loss  fluid loss

44 ATLS Specifics C - circulation (shock management) ACS Classes of Hemorrhage  classes I - IV  based on estimated blood loss and effect on vital signs

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48 ATLS Specifics C – circulation (shock management) STOP the BLEEDING  External blood loss  Internal blood loss REPLACE blood loss

49 ATLS Specifics C – circulation (shock management)  Vascular access  Direct pressure  Fluid administration  Assessment of response

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51 ATLS Specifics C – circulation (shock management) Fluid Administration  ATLS: initial 2 litre bolus of warmed Ringer’s (NS)

52 ATLS Specifics C – circulation (shock management) Crystalloid  Isotonic  Hypertonic Colloid  Albumin  Starch (Pentaspan, Voluven)

53 ATLS Specifics Fluid Administration - which fluid?  Crystalloid  massive fluid administration  diffuse edema (?worsens cerebral edema)  ?contributes to “compartment syndrome”  Colloid  no demonstrated benefit (?harm, SAFE trial)  costlier  Hypertonic saline (3%, 7.5% =/- dextran)  no demonstrated benefit (trial in progress)  hypernatremia

54 ATLS Specifics C – circulation (shock management) Blood replacement  type O  type specific  fully crossmatched

55 ATLS Specifics C - circulation (shock management)  Role of Factor VIIa  initially used for hemophilia  initiates thrombin formation by binding with exposed tissue factor  reverses coagulopathy  use after surgically accessible bleeding controlled  coag factors and platelets

56 ATLS Specifics C - circulation (shock management)  Role of Factor VIIa  parallel RCT’s in blunt/pen trauma ( JTrauma 05 ) decreased RBC use in blunt trauma better outcome in coagulopathic patients (CCM 06)  better outcome in TBI ( NEJM 05 )  multiple case reports/series showing benefit in reversal of coagulopathy and lower transfusion

57 ATLS Specifics C – circulation (shock management) Internal Stop Internal Bleeding chest, abdomen, pelvis

58 ATLS Specifics Recognition of thoracic hemorrhage  clinical  CXR  Chest tube(s)

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60 ATLS Specifics Recognition of abdominal hemorrhage  clinical  FAST  DPL  laparotomy

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63 ATLS Specifics Recognition of pelvic hemorrhage  clinical  pelvic x-ray  CT scan

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65 Damage Control Laparotomy Part 1  stop all overt arterial bleeding  pack other bleeding  control contamination  modified closure

66 Damage Control Laparotomy Part 2  return to ICU for warming, correction of coagulation and acidosis Part 3  return to OR for definitive closure

67 ATLS Specifics D – (neurologic) Disability  ATLS: rapid recognition of lateralizing injury (potentially surgically correctable)  confirmation by CT scan  emergency craniotomy for drainage

68 ATLS Specifics E - exposure / environment  remove clothing  keep covered between examinations (hypothermia)  logroll  full examination of extremities

69 Thanks Q –questions?


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