1. Trauma resuscitation a review
Prepared by Shane Barclay MD

2. Overview
Definition of Trauma The 3 groups of mortality The ‘deadly triad’ The ‘golden hour’ The concept of permissive hypotension Goals of resuscitation Steps in Trauma Resuscitation

3. Definition of trauma
The most common definition of major trauma is ‘major injury affecting more than one body system’. There is also a Injury Severity Score >15.

4. Mortality in trauma
Trauma is the leading cause of death under age 40. Most commonly are males.

5. The Golden hour
This was a concept within ATLS/Trauma Resuscitation that emphasized that to reduce mortality it was critical to manage trauma within that first hour. Realistically, in a rural setting, often it takes well over an hour for patients to be extricated and transported to the nearest hospital. In addition, several studies have shown no increased mortality when EHS spends ‘time in the field’ managing patients.

6. The ‘Golden hour’
Trauma mortality studies have consistently demonstrated that survival is related to whether or not the patient is transferred to a tertiary trauma center. Fortunately most trauma patients in BC are transported to urban tertiary centers.

7. Mortality in trauma Death from major trauma occurs in three groups:
Immediate – ie at the scene. Often due to fatal injuries to the head, heart and great vessels.
Early – occurs in minutes to hours. Often due to hemorrhage, respiratory and cardiovascular collapse.
Late – occurs days to weeks later, often due to sepsis and multi organ failure.

8. Initial Goal
From a hospital standpoint, we deal with the second group of patients, ie have not died at the scene but can die in your emergency room. Trauma Resuscitation/ATLS is designed to manage this ‘second’ group of patients in the hope of preventing death in the ER but also later on in the ICU

9. Initial Goal
Although ATLS teaches a step wise manner, really the initial goal of all this is to 1. Maintain circulating volume 2. Control/stop hemorrhage 3. Correct or prevent the ‘lethal triad’ of - Coagulopathy - Acidosis - Hypothermia

10. Initial Goal Maintain circulating volume – “permissive hypotension”
- This is a long standing concept with much written about it.
- Bottom line is there is no advantage to having a patient’s MAP > 65.
- Excessive crystalloid is associated with increased hypothermia, coagulopathy and death.
- If you think your patient is bleeding (out) don’t even consider crystalloids, give blood!

11. Initial Goal
Maintain circulating volume – “permissive hypotension” - exception to permissive hypotension is head and spinal injury, as these patients likely need a MAP > 80 to maintain cerebral perfusion.
Summary:
If no head trauma MAP < 65 give blood or fluids MAP > 65 if peripheral perfusion seems inadequate, can try some IV narcotic and that can often drop the BP, then give blood produts.

12. Initial Goal
2. Control/Stop hemorrhage. This would seem intuitive, however often the bleeding is occult or internal making management difficult. - Remember to use Tranexamic Acid. - ideally EARLY in trauma resuscitation (within 3 hrs) - Give 1 gm bolus then 1 gm over 8 hours.

13. Initial Goal
3. Prevent the lethal triad: coagulopathy, hypothermia and acidosis.

14. Initial Goal
Coagulopathies. - 25% of trauma patients bleed abnormally. - This has been called Acute Coagulopathy of Trauma Shock (and other names) - Is different than DIC - Hypothermia (cool crystalloids) and Acidosis (inadequate oxygen carrying capacity) both contribute to this coagulopathy. ie Give Blood

15. Initial Goal
Coagulopathies. From a rural perspective, most rural hospitals do not have platelets, fresh frozen plasma and in fact often limited packed red cells (ie a few bags of O neg), so treating coagulopathy is more theoretical.

16. Initial Goal Predictors of outcome?
One predictor that can help you see ‘how you are doing’ is a patient’s INR.
Why? Brain injury and hemorrhage both cause release of factors that ‘use up’ factor seven and therefore raise INR.
A second predictor is Lactate.
A third predictor is urine output. (good if producing > 50 cc/hr)

17. First steps
So.. other than becoming sweaty and tachycardic, what should you do as the team leader in a trauma code?

18. First steps The 3 most important steps are: Designate clear roles.
Ensure effective communication.
Start transfer services early.

19. First steps
1. Designate team members. 2. Call in lab, x-ray. 3. Consider ‘Code Blue’ ie get as much help as you can. 4. Get as much equipment ready as possible – RSI equipment, Ventilator, IV bags with pressure, etc If you are in a small rural hospital with limited staff, this is where you as a doctor, knowing all your equipment location, how to operate etc (ie ‘Owning the ER’) becomes so critical.

20. ABCDE

21. A B C D E Airway with C-Spine Control Breathing Circulation.
Look, Listen & Feel for breath sounds. Suction if necessary
Chin lift, jaw thrust, oral airway
Problem? Consider Intubation
Breathing
Listen to chest, look for JVD, Trachea midline?
Problem? Consider need for chest tube/pericardiocentesis?
Circulation.
BP, skin color, capillary refill
Look for obvious bleeding, apply pressure
Start 2 IV’s (Ringers), blood for CBC, lytes, Blood type/x-match
Disability.
AVPU: (Alert, Verbal Response, Pain Response, Unconscious)
Glasgow Coma Scale
Expose and Environment
Remove ALL clothing, cover with warm blanket
Log Roll (protecting spine) and inspect back.
Temperature

22. Secondary Survey – “Head to Toe”
Trauma Resuscitation
Secondary Survey – “Head to Toe”
Light in ears, eyes, mouth
Palpate scalp, facial bones, +/- C-spine and collar bones.
If OK, insert NG tube. (If patient is going to be intubated, wait, insert OG after)
Listen to heart - ? Muffled
Listen to chest, look at neck for JVD and tracheal deviation.
Palpate abdomen.
Palpate pelvic bones (down, out and distract legs).
Rectal exam (if not done on log roll) - any blood at meatus?
If normal, insert Foley – do urine preg test on females.
Palpate arms for pain, have patient move feet, bend knees, assess foot planar/dorsi flexion, assess sensation and reflexes, plantar responses.

23. Trauma Resuscitation eFAST Substernal for PCE
Abdomen for free fluid – check lungs for hemothorax
Pelvis for free fluid
Pleura for pneumothorax

24. Radiology “Trauma Series” CXR Pelvis C-Spine
Trauma Resuscitation
Radiology “Trauma Series” CXR Pelvis C-Spine

25. Trauma Resuscitation “AMPLE History” Allergies
Medications, Drugs/Alcohol Ingestion
Past Medical/Surgical history
Last meal, LMP/Pregnant
Events: History of accident and mechanism.

26. Trauma Resuscitation
Positioning the patient: Trauma or shock patients should ideally be resuscitated with the head up degrees to prevent aspiration. If spinal precautions prevent this, then you can put the whole stretcher in reverse Trendelenburg.

27. The end