1. Trauma and Cardiac Resuscitation Dr. Paul Pageau Staff Physician Assistant Fellowship Director EMUS Department of Emergency Medicine University of Ottawa The Ottawa Hospital

2. Objectives General approach to Trauma/Resuscitation patients (A-B-C-D) General approach to Trauma/Resuscitation patients (A-B-C-D) Approach to patient with multisystem trauma (MVC, penetrating, and other) Approach to patient with multisystem trauma (MVC, penetrating, and other) Approach to asystole/V-fib/STEMI patient and resuscitation, including drugs and therapeutic hypothermia Approach to asystole/V-fib/STEMI patient and resuscitation, including drugs and therapeutic hypothermia Trauma code: Outline role of Emergency Physician, Emergency team, TTL, and other services Trauma code: Outline role of Emergency Physician, Emergency team, TTL, and other services

3. General Principles of Resuscitation Preparation Preparation Triage (multiple and mass casualties) Triage (multiple and mass casualties) Teamwork Teamwork Leadership Leadership Communication Communication Crisis Resource management Crisis Resource management Situation awareness Situation awareness

4. Trauma A-B-C’s Primary Survey A – Airway and C-spine A – Airway and C-spine B – Breathing and Ventilation B – Breathing and Ventilation C – Circulation and Hemorrhage control C – Circulation and Hemorrhage control D – Disability (Neuro) D – Disability (Neuro) E – Exposure and Environment control E – Exposure and Environment control

5. Adjuncts to Primary Survey Monitoring Monitoring Catheters Catheters eFAST eFAST Consider transfer/ Trauma Code Consider transfer/ Trauma Code

6. Secondary Survey Head to Toe (finger or tube) Head to Toe (finger or tube) History and Physical examination History and Physical examination Continual reassessment of Vital signs Continual reassessment of Vital signs Complete Neuro exam Complete Neuro exam Specific radiologic evaluation (CT) Specific radiologic evaluation (CT)

8. Code One Trauma EP on duty +- Res/students, 3 RN’s (Chart, Action/Task) Trauma Team Leader (Gen Surgery or Emerg staff) Trauma Team Leader (Gen Surgery or Emerg staff) Gen Surgery Sr Resident Gen Surgery Sr Resident Anaesthesia Resident Anaesthesia Resident 2 Respiratory Therapists 2 Respiratory Therapists 2 Patient Transport Workers 2 Patient Transport Workers Advance care nurse practitioner – trauma Advance care nurse practitioner – trauma Clinical manager in ED Clinical manager in ED Trauma coordinator Trauma coordinator Security Security OR is notified OR is notified Trauma Dept is notified Trauma Dept is notified

9. Code One Trauma TTL is EP on duty until TTL on call arrives (<20min) TTL is EP on duty until TTL on call arrives (<20min) Gen Surg Resident may assume TTL role depending on Level of training Gen Surg Resident may assume TTL role depending on Level of training Anaesthesia takes direction from TTL but mainly manages airway +- pain medication Anaesthesia takes direction from TTL but mainly manages airway +- pain medication RN’s: IV catheters, monitoring, charting, other catheters, facilitating, anticipating RN’s: IV catheters, monitoring, charting, other catheters, facilitating, anticipating RT’s: Airway assistance, Ventilation, monitoring RT’s: Airway assistance, Ventilation, monitoring

10. Trauma Case 1 Hx: 11yo ATV no helmet, Collided with tree 11yo ATV no helmet, Collided with tree Altered LOC, hematoma ant scalp, Ant chest contusion Altered LOC, hematoma ant scalp, Ant chest contusion EMS Vitals: HR130, BP80/60, Sats 90%RA, GCS=10, PERL EMS Vitals: HR130, BP80/60, Sats 90%RA, GCS=10, PERL Long transport from Trail Long transport from Trail IVF 1L IVF 1L

11. Trauma Case 1 Boarded and collared wet clothes Boarded and collared wet clothes Vitals HR120, BP90/65, Sats 90% on O2, RR25, GCS=11, T34.8 tymp Vitals HR120, BP90/65, Sats 90% on O2, RR25, GCS=11, T34.8 tymp Vomitting Vomitting Primary Survey: Airway: moaning, emesis on face Airway: moaning, emesis on face Cspine protected Cspine protected Decreased A/E on Right, dull percsn Decreased A/E on Right, dull percsn Trachea midline Trachea midline Decreased Cap refill Decreased Cap refill PERL PERL FAST pos pleural fluid, neg peritoneal fluid FAST pos pleural fluid, neg peritoneal fluid

12. Trauma Case 1 pt vomits just prior to ETT pt vomits just prior to ETT roll onto side and suction roll onto side and suction pt develops pulseless VF when rolling pt develops pulseless VF when rolling defibrillate 2J/kg X1 defibrillate 2J/kg X1 vitals return to baseline vitals return to baseline

13. Trauma Case 1 Secondary Survey: Right hemotympanum Right hemotympanum Forehead abrasion and hematoma Forehead abrasion and hematoma Right chest contusion Right chest contusion Pelvis stable, Abdo soft Pelvis stable, Abdo softDisposition: Transfer to Tertiary care/ICU Transfer to Tertiary care/ICU

14. Trauma Case 2 Large Community Hospital. OB/Anaesthesia in house, Peds often in house Large Community Hospital. OB/Anaesthesia in house, Peds often in house EMS presents unannounced with 35yr female MVC, VSA, 30wks + pregnant. EMS presents unannounced with 35yr female MVC, VSA, 30wks + pregnant.Hx: 35 yo female. 30 wks+ pregnant, Belted passenger, T-boned,. 35 yo female. 30 wks+ pregnant, Belted passenger, T-boned,. EMS on site <5min: VSA, CPR and epinephrine X2, intubated, 1L NS EMS on site <5min: VSA, CPR and epinephrine X2, intubated, 1L NS Arrival to ED after 25 mins downtime Arrival to ED after 25 mins downtime

15. Trauma Case 2 Interventions?: OB stat OB stat Peds Peds Primary Survey: Intubated Intubated Multiple right rib fractures – soft chest ?Air Entry on R Multiple right rib fractures – soft chest ?Air Entry on R VSA – CPR in progress VSA – CPR in progress

16. Trauma Case 2 Interventions?: perimortem C/S perimortem C/S ?Chest tube R ?Chest tube R Secondary Survey: Pupils fixed dilated Pupils fixed dilated blood from L ear and visible brain matter R skull blood from L ear and visible brain matter R skull Pregnant abdomen Pregnant abdomen Pelvis unstable Pelvis unstable

17. Cardiac Arrest and Resuscitation Principles: Chain of survival: Recognition and activation Recognition and activation Early CPR Early CPR Rapid defibrillation Rapid defibrillation Advanced life support Advanced life support Integrated post-cardiac arrest care Integrated post-cardiac arrest care

18. Cardiac arrest Call for help, Defibrillator, CPR Call for help, Defibrillator, CPR Shockable rhythm?  200J  CPR Shockable rhythm?  200J  CPR Asystole/PEA  CPR  Epi 1mg q3-5min, Atropine 1mg q3-5min X3 Asystole/PEA  CPR  Epi 1mg q3-5min, Atropine 1mg q3-5min X3 Check for shockable rhythm q2min CPR Check for shockable rhythm q2min CPR Treat contributing factors (H’s and T’s) Treat contributing factors (H’s and T’s) Consider antiarrhythmics: amiodarone 300mg, or Lidocaine 1mg/kg, Consider antiarrhythmics: amiodarone 300mg, or Lidocaine 1mg/kg, Consider magnesium 1 – 2 gms for torsades Consider magnesium 1 – 2 gms for torsades

19. ROSC Evaluate for STEMI  PCI/code STEMI Evaluate for STEMI  PCI/code STEMI In comatose pts evaluate for therapeutic hypothermia In comatose pts evaluate for therapeutic hypothermia Stabilize, monitor, definitive care Stabilize, monitor, definitive care

20. Objectives General approach to Trauma/Resuscitation patients (A-B-C-D) General approach to Trauma/Resuscitation patients (A-B-C-D) Approach to patient with multisystem trauma (MVC, penetrating, and other) Approach to patient with multisystem trauma (MVC, penetrating, and other) Approach to asystole/V-fib/STEMI patient and resuscitation, including drugs and therapeutic hypothermia Approach to asystole/V-fib/STEMI patient and resuscitation, including drugs and therapeutic hypothermia Trauma code: Outline role of Emergency Physician, Emergency team, TTL, and other services Trauma code: Outline role of Emergency Physician, Emergency team, TTL, and other services