1. Trauma Resuscitation Shelley Atkinson RN, MSN, ANP-BC, ACNP- BC

2. Objectives Identify the correct sequence of priorities for assessment of a multiple injury trauma patient. Identify the principles outlined in the primary and secondary evaluation surveys to the assessment of a multiple injury patient. Identify guidelines and techniques in the initial resuscitative and definitive-care phases of treatment of a multiple injury patient.

3. Injury Statistics Leading cause of death for ages 1-44 $ 500 billion dollar annual cost Estimated 20-50 million injuries occur per year (40 % of emergency room visits) Leading causes of trauma are motor vehicle crashes, falls, and assaults

4. Trimodal Death Distribution Death due to injury occurs in one of three periods or peaks Care provided during each of these periods impacts patient outcomes

5. Trimodal Death Distribution First peak – occurs within seconds to minutes of injury Second peak – occurs within minutes to several hours following injury Third peak – occurs several days to weeks after initial injury

6. Advanced Trauma Life Support (ATLS) Assess the patient’s condition rapidly and accurately Resuscitate and stabilize the patient according priority Determine if patient’s needs exceed a facility’s resources/or doctor’s capabilities Arrange for transfer (what, where, when, who, and how)

7. ATLS Assure that optimum care is provided and level of care does not deteriorate at any point during evaluation, resuscitation, or transfer process

8. What is a Level One Trauma Center? A hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries.

9. Level One Criteria Airway/Breathing Unstable airway/unsecure airway Patients with severe maxillofacial injuries Patients requiring immediate airway intervention Facial burns / suspected inhalation injury Moderate to severe Respiratory distress Sub Q air in face, neck, or chest

10. Level One Criteria Circulation Systolic BP 120 Witnessed cardiac arrest from trauma Uncontrolled/Arterial Bleeding with shock Spinal/Neurogenic Shock

11. Level One Criteria CNS GCS ≤ 8 Head injury with LOC > 5 min Known spinal cord injury Neurologic deficits with suspected spinal cord injury (any level)

12. Level One Criteria Chest/Abdomen/Pelvis Chest/Abdominal/Pelvic Injury with shock Chest wall injury – Flail chest – Sucking chest wound – Subcutaneous air Pregnancy ≥ 24 weeks with significant mechanism of injury

13. Level One Criteria Extremities Multiple long bone fractures with shock Mangled Extremity or Amputation – above wrist/ankle

14. Level One Criteria Mechanism of Injury Penetrating trauma to the head, face, torso (chest, abdomen, buttocks, back) Ejection from vehicle Fall from 20 or more feet with presence of other Level I criteria Electrocution/Electrical Injury with entry/exit wounds

15. Level One Criteria Mechanism of Injury Burns > 20% TBSA or burns combined with any other injury Massive crush injury

16. Pre-hospital care

17. Initial Assessment Primary survey and resuscitation of vital functions are done simultaneously. A team approach

18. Primary Survey ABCDEs Airway with cervical spine protection Breathing Circulation with hemorrhage control Disability: Neurologic status Exposure/Environment

19. What is the number one priority during the initial assessment of a trauma patient? A. Airway B. Airway C. Airway D. All of the above

20. Airway Obstruction Recognition Look Agitation/Obtunded Decreased air movement Retraction Deformity Airway debris Listen Normal speech- no obstruction Noisy breathing – obstruction Gurgle Stridor Hoarseness

21. Inadequate Breathing Look Cyanosis Change in Mental Status Chest asymmetry Tachypnea Neck vein distention Paralysis Feel Sub Q emphysema/chest wall crepitus Tracheal deviation Listen “I can’t breathe” “I am dying” Stridor, wheezes Decreased or absent breath sounds

22. Which way for the Airway?

23. Rapid Sequence Intubation Be prepared to perform a surgical airway in the event that airway control is lost Pre-oxygenate patient with 100% oxygen Administer analgesic / sedative (IV) if feasible Apply pressure over cricoid cartilage – Debatable Administer a paralytic IV Perform chin lift/jaw thrust

24. Rapid Sequence Intubation After the patient relaxes, intubate orotracheally Inflate cuff and confirm placement – auscultate and determine CO 2 in exhaled air Release cricoid pressure Ventilate CXR

25. Adjuncts to Primary Survey ECG CO2 detector Pulse oximetry Vital Signs

26. Primary Survey Circulation with Hemorrhage Control Control hemorrhage Activate trauma (Massive Transfusion Protocol) – 6U pRBC, 4U FFP, 1 Platelets – MD activation only Judicious use of crystalloid

27. 6 areas potential blood loss Chest Abdomen Retroperitoneum Pelvis Long bones / Soft tissue Scalp …the ground

29. Trauma Majority deaths occur in 1 st few hours after injury Hemorrhage largest % deaths within 1 st hour Hemorrhagic shock and exsanguination – 80% deaths in OR – 50% deaths 1 st 24 hrs after injury Very few hemorrhage deaths after 1 st 24 hours Only CNS injury more lethal

30. Special Considerations In Diagnosis and Treatment of Shock Age Athletes Pregnancy Medications Hypothermia Pacemakers

31. Vascular Access 2 large-caliber, peripheral IVs Central access – femoral – jugular – subclavian Intraosseous Obtain blood for crossmatch Trauma panel – CBC, BMP, coags

32. Hemorrhagic Shock Class I Class IIClass IIIClass IV EBL 2000 HR 100 >120 >140 BP NL NL LOW LOW UO >3020 - 30 5 - 15 MIN ACS-COT 1993

33. Direct Effects of Hemorrhage Class I – (up to 15% blood volume loss) Exemplified by the patient that has donated one unit of blood Class II – (15% - 30% blood volume loss) Uncomplicated hemorrhage for which crystalloid fluid resuscitation is required

34. Direct Effects of Hemorrhage Class III – (30% - 40% blood volume loss) Complicated hemorrhagic state in which at least crystalloid infusion is required and perhaps also blood replacement Class IV – (more than 40%) Considered a pre-terminal event, and unless very aggressive measures are taken, the patient will die within minutes

35. Fluid Resuscitation Balance organ perfusion with risk of re-bleeding – may reverse vasoconstriction of injured vessel – Dislodge early clot – Dilute coagulation factors – Cool patient – Induce visceral swelling

36. Too much fluid?

37. Adequacy of Resuscitation Clinical Variables Mentation Pulse, pulse pressure, BP Urine output Clot formation Temperature Lactate/base deficit

39. Primary Survey - Disability Neurologic Evaluation Baseline neurologic evaluation GCS scoring Pupillary response **Observe for neurologic deterioration

41. Head Trauma Severe CHI (GCS < 9) vulnerable to secondary brain injury Hypotension doubles mortality Hypoxia and hypotension increases mortality by 75% Normovolemia goal (dehydration harmful) Hypertonic saline or Osmotic Agent (mannitol)

42. Head Trauma Hyperventilation used cautiously – only used if patient rapidly deteriorates PCO 2 no lower than 30-35 Prolonged hyperventilation can produce cerebral ischemia and secondary brain injury Mannitol useful – after adequate volume resuscitation

43. Spinal Cord Injury Neurogenic Shock – Consider hemorrhage first… Maintain spine immobilization Fluid or no fluid? Vasopressors

44. Septic Shock Uncommon immediately after injury May occur several hours after injury (especially if transfer to emergent facility delayed) May occur in penetrating abdominal injuries – contamination of intestinal contents into peritoneal cavity

45. Primary Survey - Exposure/Environmental Control Completely undress the patient Prevent hypothermia

46. Deadly Triad Hypothermia Acidosis Coagulopathy

47. Hypothermia (HT) Frequent in trauma/massive transfusions Trauma-related HT considered poor prognostic sign Mortality directly  to degree and duration Inhibits coagulation factor synthesis, prolongs PT and PTT Severely affects platelet count and function Attenuates vital CV compensatory responses, predisposes to arrhythmias

48. Re-warming Aggressive therapy associated with significant decrease in: – blood loss – fluid requirements – organ failure – LOS in ICU – mortality rate

49. Secondary Survey Begins after ABCDE is completed Resuscitative efforts underway Each region of the body is completely examined

50. Trauma imaging Chest x-ray Pelvis x-ray FAST – focused assessment sonography in trauma DPL (center-dependent) – diagnostic peritoneal lavage CT scan – Traumagram

51. Adjuncts Secondary Survey Foley NGT ABG/lactate – If actively resuscitating

52. Primary Goal of Initial Operation for a Trauma Patient Damage Control Hemorrhage Control Contamination

55. Case Study #1 20 year old male, unrestrained driver, in a motor vehicle that collides into a large tree. +LOC at the scene and unresponsive. Starred windshield. Life flight transported to VUMC. VS: 120/70 mm Hg, HR= 110-115, RR= 15 Receiving oxygen 100% NRB

56. Question #1 What is the number one priority during the initial assessment of this trauma patient? 1-Airway 2-Breathing 3-Circulation 4-Disability

57. Question #2 What Level One Criteria does the patient meet? 1- GCS < or = 8 2- Head injury with LOC > 5 min 3- moderate to severe respiratory distress 4- all the above

58. Question #3 True or False. The patient’s need for airway protection and ventilation is due to unconsciousness. 1- True 2- False

59. Question #4 Which two steps listed below are early steps in the RSI procedure? 1- Pre-oxygenate with 80% oxygen & apply cricoid pressure 2- perform chin lift/jaw thrust to open airway& pre-oxygenate with 100% oxygen 3- administer a paralytic & ventilate

60. Question #5 How do I know the ETT is in the correct position? 1- presence of CO2 in the end tidal CO2 detector only? 2- equal breath sounds bilaterally and gurgling in the epigastrium 3- presence of CO2, equal bilateral breath sounds and CXR

61. Case Study #2 20 year old male assaulted. GSW to right chest and left lower extremity. Patient is c/o chest pain, SOB, and left lower extremity pain HR= 110; BP=120; RR = 30; SaO2= 90% on 100 % NRB; No BS on Right

62. Question #1 True or False. This patient does not meet Level One Criteria. 1- True 2- False

63. Question #2 What trauma imaging is needed for this patient? 1- CXR only 2- CT of the chest 3- CXR, CT chest/abd/pelvis, Left femur XR 4- Head CT

64. What is wrong with this CXR?

65. Question #3 What do you think is wrong with this patient based on the CXR provided? 1-labored breathing due to pain 2-spleen laceration 3-pneumothorax 4- hemothorax

66. Question #4 What should be assessed in the secondary survey? 1-pulses of right leg only 2-roll the patient for posterior check 3-roll patient over (posterior check) and assess pulses (Fem, DP,PT) 4-secondary survey excluded because the patient states, “I am fine”

67. Case Study #3 18-20 year old male unrestrained passenger. Car hit a bridge. Driver DOA. Reported by EMS, “Initially awake, not acting right”. Gradually more confused & verbally uncooperative. 2L NS in air craft. BP=110 and decreasing. HR=120. RSI per life flight.

68. Question #1 What signs/symptoms are the patient exhibiting that he needs resuscitation? 1- decreased mentation 2- increasing HR and decreasing BP 3- Both

69. Question #2 The patient has increasing HR =130s BP= 84P What stage of shock is the patient in? 1- Stage 1 2- Stage 2 3- Stage 3 4- Stage 4

70. Question #3 The patient was given 2L of NS during his flight and was unresponsive to this. What is the next step? BP 84P HR=130 1- order a 3 rd liter of crystalloid 2- order 2 U PRBCs 3- do nothing 4- give 4 FFP

71. Question #4 What trauma imaging is needed at this time? Secondary survey noted left lower abdominal ecchymosis. 1- CXR 2- CT chest/abd/pelvis 3- FAST exam 4- one and two only

72. Question #5 True or False. A FAST exam (focused assessment sonography)is used to rapidly identify hemorrhage or potential hollow viscous injury 1-True 2-False

73. Question #6 FAST study positive for a large amount of fluid in the abd. What intervention is needed for the patient at this time? 1- Go to the operating room 2- Activate the trauma exsanguination protocol 3- Go immediately to CT scan 4- Both one and two

74. Question #7 What is the trauma exsanguination protocol or Massive transfusion protocol? 1- 2 L crystalloid 2- 2 U PRBC 3- 2 L crystalloid and 2 U PRBC 4- 6 U PRBC, 4 U FFP, 1 pack plts

76. References Acute Trauma Life Support Course – Retrieved from American College of Surgeons Website http://www.facs.org/trauma/atls/information.html on July 1, 2012. http://www.facs.org/trauma/atls/information.html on July 1 Guillamondegui, Oscar MD, MPH, FACS, Associate Professor of Surgery, Medical Director, Trauma ICU, Director of Trauma Education, Vanderbilt University Medical Center. Atkinson, S., Collins, N., Martin, M., Morton, M., Marshall, K. (2012) Outcomes of Adding ACNPs to a Level One Trauma Service with the Goal of Decreased Length of Stay and Improved Patient, Physician and Nursing Satisfaction: A pilot study.