Initial Management Flashcards
Commonly used terms to describe major trauma 5
Death after trauma
Admission to ICU for 24hrs w/ mech vent
Serious injury to >2 body systems
Injury severity score >12
Urgent surgery for Inter cranial, intra thoracic or intra abdominal injury. Fixation of pelvic or spinal fractures
Stages of care 4
Pre hospital
ED
Inpatient
Rehabilitation
Goals of ED care of major trauma 3
Seek and treat life threats
Expedite delivery of the patient to the appropriate inpatient service
Minimise morbidity from preventable errors and complications
RAPTOR
Resuscitation with angiography, percutaneous techniques and operative repair
Disposition major trauma patient 4+2
Radiology
Theatre
ICU
Ward
Inter hospital transfer
Hybrid Suite RAPTOR
Roles of ED in major trauma
Receive pre notification activate trauma system
Receive patient
Commence the initial assessment and resuscitation
Coordinate initial management and investigation
Refer to the appropriate inpatient services or external trauma centre
Arrange disposition of the patient: admission or transfer
IMIST
Identification
Mechanism
Injuries
Signs vitals
Treatment
Exposure and control of life threatening haemorrhage
All dressings must be removed
Tourniquets should be assessed and optimised
Not over clothing
Endotracheal tube check 6
Confirm end tidal CO2
Confirm current insertion distance at lips/teeth matches that documented by pre-hospital team
Check cuff pressure
Auscultate for breath sounds
Perform chest XR by assessment doctor
NG tube placement
Anterior neck examination - life threatening conditions not to miss
TWELVEC
Tracheal deviation - tension PTX
Wounds and swelling - vascular injury or haematoma which can cause compression/obstruction of airway
Emphysema - subcutaneous emphysema can be caused by an injury to the airway or tracking from PTX/Pmediastinum
Laryngeal crepitus - laryngeal fracture*
Veins - distended neck veins may indicate cardiac tamponade or tension PTX
Oesophagus - ability to swallow
Carotids - assess for bruising, swelling and bruits over the carotids
Mechanisms and signs of laryngeal fracture 3+4
Cautions
Hanging
Clothesline injuries
Direct blow to neck
Ligature marks
Anterior neck bruising and swelling
Throat pain swelling
Voice change
Do not palpate
Disrupting laryngeal anatomy and obstructing airway
Breathing and chest trauma
Aims 3
To optimise oxygenation and effective ventilation
To rapidly identify and tear TensPTX with pleural decompression and intercostal catheter
Seek and treat other life threats in the chest
Immediate life threats in the chest
ATOM-FC
Aortic transection - shearing, different from dissection
Tension PTX/Tracheo-bronchial injury - non re-inflating lungs despite decompression: large hole or defect in airway or lung
Open PTX -air drawn through wound on insp and expelled on exp
Massive haemothorax
Flail segment - paradoxical inspiration. Not all are visible
Cardiac tamponade - eFAST. Becks triad not sensitive or specific but academic!
Absence of Tension PTX on initial assessment - when is there a risk of it developing
Absence initially does not exclude.
Can occur over minutes to hours
Risk - after intubation, +ve pressure as air is forced through a defect
Universal, Common, Inconsistent and rare findings in tension PTX
Universal - chest pain, respiratory distress
Common findings (50-75%) - tachycardia, ipsilateral decreased AE
Inconsistent (<25%) - low SpO2, hypotension, tracheal deviation
Rare findings (~10%) - cyanosis, hyper resonance, decreased LOC, ipsilater hyper expansion/hypo mobility
Classically taught signs of tension PTX
Tracheal deviation
Increased JVP or distended neck veins
Impossible to ascertain in acute trauma setting and limited/no practical use
Signs of tension PTX in ventilated patients
Most to least common
Universal - rapid onset, immediate and progressive hypoxia, immediate reduction in cardiac output/BP
Common findings - tachycardia, high ventilation pressure, ipsilateral chest hyper expansion, hypo mobility decreased air entry
Inconsistent findings - surgical emphysema, venous distension
Recommendations for immediate chest decompression with awake pts with suspected Tension PTX in abcence of XR
(5)
SpO2 <92% on O2
Systolic BP <90mmHg
Respiratory rate <10 (agonal)
Decreased level of consciousness despite oxygen therapy
Cardiac arrest -> bilateral finger or tube thoracostomy
Obstructive shock mantra
Seek and treat obstructive shock, only give blood if bleeding
Open PTX management
Small+Large
Sml - Occlusive dressing
Lrge- sutured close then occlusive dressing.
Followed by intercostal catheter inserted.
NB alternatively monitor and place intercostal catheter only if needed.
Open PTX
3 sided dressings -PEARL
Theoretical risk of Tension pneumothorax with 4 sided dressing prevented with 3 sided but no evidence to support this and in reality difficult to make and apply
Aims in circulation and haemorrhage control
(5)
Assess end organ perfusion/signs of shock
To seek and treat obstructive shock Tens PTX,tamponade
Seek and treat haemorrhagic shock
Identify and control source of bleeding
Obtain adequate vascular access and commence appropriate fluid/blood product resuscitation
Goal of circulation in short (3)
Find the bleeding
Stop the bleeding
Correct the deficiencies
Two distinct categories of bleeding
External compressible bleeding
Internal non compressible
Large volume internal bleeding areas 5*
Four and one on the floor
Thighs
Pelvis
Abdomen + retroperitoneal*
Chest
Should you clamp a chest drain if massive haemorrhage occurs?
(3)
No.
This will conceal blood loss, impair ventilation/oxygenation and potentially lead to obstructive shock/tension physiology
Average volume in the pleural space
Circulating volume of blood
3L
5L
Meaning you can bleed more than half your circulating volume into one pleural doace
Seatbelt bruising - what does this indicate and what does it warrant
Indicates significant blunt force, heralding serious intra-abdominal injury
Warrants admission and observation even with normal CT due to risk of delayed complications
Pelvic binder prognosis
No effect on mortality
Benefits reduction in transfusions requirements
Benefit in open book/AP compression, can worsen lateral compression and vertical shear
Palpating the pelvis
How
How if unstable fracture suspected/known already
Single gentle medically directed compression from the iliac crests laterally
Should not be
Never spring or rock the pelvis
Most pelvic injuries that cause haemodynamic instability feel like
Orthopaedically unstable
Feel bones move under your hands
Blood loss from femur, tibia
1000-1500
500-1000
Very general estimate
Haemodynamic compromise and +FAST scan (abdomen)
Other causes of shock have been treated/excluded
Indication for urgent laparotomy
Windows in FAST (4)
RUQ - Posterior right sub hepatic space (hepato-renal fossa/Morrisons pouch)
LUQ - peri splenic space
Suprapubic - pelvic fluid
Pericardium - haemo-pericardium/tamponade
Poiseulle’s law
Flow is proportional to the 4th power of the radius and inversely proportional to the length of the tubing
Double diameter = x16
VBG parameters
(4)
Acid base status and lactate- surrogate markers for shock
Hb
Electrolytes (K before sux and RSI)
Ionised Ca
-stored blood Ca deplete
-lowering Ca negatively impacts coagulation
Target >0.8
Fluid resus take home message
Avoid saline
Only give blood if bleeding
Ideal ratio of blood products
Yet to be defined but many centres use 1:1:1
RBC:FFP:Plts
Permissive hypotension
Targets (2)
Consideration
Systolic BP >80
Or
MAP >65 + palpable radial artery and O2 waveform
Traumatic brain injury
Permissive hypotension in TBI
(2)
50-69 >100
15-49 >110
Indications for PR on log roll
(2)
Proven spinal injury - anal tone helps differentiate complete and incomplete cord injuries
Suspicion of low colonic/rectal injury or perforation
All other patients - peri anal sensation is adequate for spinal cord function
Specific checks Primary survey
(8)
Airway patency
Adequate oxygenation/ventilation/ventilation settings
Volume status
E-fast
Intercostal catheters secured and functioning
IV access is secure
Bloods sent to lab
Complete check of updated vitals
OPA average size adults
2,3,4
NPA adult sizing
Female 6-7mm
Male 7-8mm
Written on flange
Pre oxygenation options and summary
BVM (perfect seal) FiO2~80%. Use if you can maintain seal for 3-5mins or if assistance required with ventilation
NRM+/-NC can’t maintain perfect BVM seal for 3-5mins
What is delayed sequence induction
Use of sedation in agitated, spontaneously breathing patient, prior to RSI to tolerate NIV
Not recommended for trauma patients
Apnoeic oxygenation
Prolonged by NC
Proposed sub atmospheric pressure difference between O2 absorption (250mls/min) and CO2 (10ml/min) generating flow of gas from pharynx to the alveoli
ET intubation indications trauma
(6)
Airway obstruction
Hypoventilation
Persistent hypoxaemia <90% despite O2
Severely impaired GCS<8
Severe haemorrhagic shock
Cardiac arrest
ET intubation indications smoke inhalation
5
Airway obstruction
GCS<8
Major cutaneous burns >40%
Major burns/Smoke inhalation with delayed transport expected
Impending airway obstruction from facial/oropharyngeal burn/airway injury on endoscopy
(Humanitarian
Other reasons to consider intubation in trauma patients (5)
Face/neck injury with potential for airway obstruction
Moderate consciousness impairment GCS 9-12
Persistent combativeness pharm refractory
Resp distress
Preoperative Mx
Waiting period after induction agents
45-60secs
Can be slower in shocked patients and in non depolarising NM blockers (roc)
ET laryngoscopy steps
(11)
- Open mouth
- Insert laryngoscope/epiglottoscopy, secure tongue to midline
- Tip into vallecullae+optimal laryngeal manipulation (ELM)
4.laryngoscope force, up and away, no tilting - Insert bougie, from side
- ETT over bougie handover of bougie. Record distance (20-21f/22-23m)
- Inflate ETT cuff 10-20mls, cuff manometer
- Connect BVM to waveform capnograph. Continuous CO2 trace
- Secure with cotton tube ties or commercial device
- Confirm placement
- OG tube placement
Confirm placement of ETT
(7)
Visualisation of tube through chords
ETCO2 trace present and maintained
Fogging of tube with exhalation
Auscultation of breath sounds L/R chest and axillae
Auscultation of epigastrium - gurgling in stomach implies oesophageal placement
Maintenance of sats/abscence of hypoxia
CXR
Sodium thiopental
Pros (3)
Cautions
Rapid onset and clearance
Reduction of cerebral oxygenation consumption
Anticonvulsant effects
Inhibition of sympathetic response of CNS, therefore reduced myocardial contractility and systemic vascular resistance, potential hypotension
Sodium thiopental
Presentation
Preparation
Final conc
Dose
Presentation: 500mg powder
Preparation: Draw up 20ml NaCl
Final conc: 25mg/ml
Dose: 3mg/kg rapid IV push.
Shocked trauma patients 1-2mg/kg
80kg=210mg=8.4ml
Ketamine
Benefits
Concern?
Significant analgesia - opioid receptor
Anaesthesia
Amnesia - NMDA receptor neuroinhibition
Cardiovascularly stable - catecholamine releasing effect
Raise in ICP
Ketamine
Presentation
Preparation
Final conc
Dose
Presentation: 200mg in 2ml
Prep: Draw up in 20ml NaCl
Final conc: 10mg/ml
Dose: 1.0-2.0mg/kg IV
Propofol (class)
Pros
Cons
Non-barbituate hypnotic agent
Rapid deep sedation
Significant relaxation of laryngeal musculature
Excellent induction agent for stable non emergent patients (elective theatre)
Potential for hypotension
Myocardial depression
Reduction in cerebral perfusion
Propofol
Presentation:
Preparation:
Final conc:
Dose:
Presentation: 200mg in 20ml
Preparation: draw up undiluted
Final conc: 10mg/ml
Dose: titrate to effect ~1.0-1.5mg/kg
Trial 4ml bolis
Dose reduced in shocked patients
Suxamethonium
MOI
Depolarising muscle relaxant
Non competitively at the ACh receptor
Fasciculations then paralysis
Suxamethonium
Presentation:
Preparation:
Final conc:
Dose:
Onset:
Duration:
Presentation: 100mg/2ml
Preparation: draw up undiluted
Final conc: 50mg/ml
Dose: 1.5mg/kg
Onset: 30-60 seconds
Duration: 6-12 mins
Post intubation Hypotension
Pneumonic (7)
AH-SHITE
Anaphylaxis, Acidosis
Heart - tamponade, pulm hypertension
Stacked breaths
Hypovolaemia
Induction agents (sedation)
Tension Pneumothorax
Electrolytes
Needle cricothyroidotomy jet ventilation timing
Maximum maintenence time
4-5 second O2
20 seconds off
2 second jets after when sats drop by 5%
30 minutes
Indications for cricothyroidotomy
Can’t intubate can’t oxygenate
3 attempts at each BVM/ETT/LMA without success
The vortex
Optimisation strategies for difficult airways
(5) things that can be changed
Manipulation
Adjuncts
Size/type of ETT
Suction
Pharyngeal muscle tone
Indications of awareness (5)
Eye-watering
Sweating
Tachycardia
Tachypnoea
HTN
Maintenance regimes
Propofol
Ketamine
Morphine and midazolam
Propofol: Start 50-100mg/hr=5-10ml/hr and titrate
Ketamine: Start 1mg/kg/hr and titrate
Morphine and midazolam 0.1mg/kg/hr and titrate
Ventilation settings
Tidal volume
~8ml/kg
80kg = 640ml
Ventilation settings
RR
8-10/min
Ventilation settings
PEEP
5cmH20
Ventilation settings
Peak pressure
<30cmH20
Ventilation settings
Peak pressure
<30cmH20
Ventilation settings
FiO2
Guided by pre intubation oxygen requirements
How to titrate RR in intubated patients
ABG - PaCO2
Head injuries - normocarbia 35-40
Thoracic injuries - permissive hypercapnia to favour gentle ventilation
Arterial to ET CO2 gradient
Make note of ETCO2 when taking ABG
Target PaO2 intubated patients TBI
PaO2 80-100mmHg
Neuroprotective strategies
(7)
Maintain CPP - SBP >90mmHg, Head up 30degrees (or tilt if spinal precautions)
Ensure adequate sedation +/- paralysis
Normoxia (PaO2-100mmHg)
Normocarbia (PaCO2 35mmHg)
Normothermia (avoid hyperthermia)
Normoglycaemia (BSL<10mmol/l)
Avoid seizures
Blunt thoracic injuries
Percentage responsible for trauma deaths
Percentage of all chest trauma
20-25%
Major contributor in 50%
90-95% (rise in the UK)
Percentage of chest trauma requiring operative intervention
10% (thoracotomy)
Remainder requiring supportive care including pleural decompresison and drainage
Immediate traumatic death usual causes
Rupture of myocardial wall or thoracic aorta
Causes of early traumatic death (30mins-3hours)
Tension PTX
Cardiac tamponade
Airway obstruction
Uncontrolled thoracic haemorrhage(torn Pulm vessels, lung lacerations, intercostal artery lacerations)
Crico
Anatomy
Technique
Crico-thyroid membrane - close to cricoid to avoid cricothyroid artery and vein
Scalpel-Finger-Bougie
Resp exam: Inspection
(8)
Respiratory distress - effort/accessory/tripodding
Dilated/distended neck veins - insensitive for Tamp/PTX
Open wounds/penetrating injuries
Abrasions/bruising
Chest wall deformity
Asymmetric chest wall movement
Flail chest segment
Posterior chest wall injuries
Resp exam: Palpation
(3)
Tracheal deviation - insensitive
Tenderness or crepitus from rib fractures
Subcutaneous emphysema
Resp exam: Percussion (2) and Auscultation (1)
Hyper-r3sonant - PTX
Dull - Haemothorax
Reduced breath sounds
Both difficult in noisy resucitation room
Breathing and Thoracic 2ry survey conditions to look for (5)
Pulmonary contusion - fluffy opacities CXR, haemoptysis, gradual worsening
Cardiac contusion - Abnormal ECG, raised Trop, abnormal Echo
Blunt aortic injury - CT, sought in pts with seatbelt marks or rapid deceleration
Oesophageal injury
Diaphragmatic rupture
CXR Signs (5)
Ipsilateral
- Sharp lung edges running parallel to chest wall
- Diaphragm depression
-Hyper expansion (widened spaces between ribs)
-Deep sulcus sign: deep, lucent, lateral costo-phrenic angle
Contralateral
-Mediastinal shift
Chest decompression steps
Supplemental O2 NRB 15L/min
Prep and drape/Sterile precautions
Mark and incise skin (w/local) Rule of 4’s and 5’s (adults) Rule of 4’s (paeds’s)
Blunt dissection with curved Pean’s/Kelly’s/Long forceps - through intercostal muscle and pleura
Insert finger, clear tract for tube. Paeds use mosquito
After decompression, insert 28-32Fr intercostal catheter and connect to underwater seal drain
Adult Rule of 4’s and 5’s
4-5cm skin incision
45 degree angle (along rib)
4th-5th intercostal space (bottom of axillary hairline)
Mid-anterior axillary line
Paediatric Rule of 4’s
4th (or 5th) intercostal Space
Size = 4 xETT size = 4x[(age/4)+4]
Insert to 4cm mark lastr hole is 4cm inside chest
Intercostal catheter placement after finger decompression in ventilated patients
Can potentially be delayed as ventilator is provided positive pressure ventilation
Occlusive dressing should be applied
Position for Needle decompression
Only if equipment not available for finger thoracostomy
4th-5th Mid axillary
Arrest mechanism following Tension PTX
Classically taught reduced venous return and cardiac arrest but more likely respiratory 2ry to hypoxia
Myocardial hypoxia
Central hypoxaemia - suppresion of respiratory centre
Hypoxic intercostal muscles
Depression of ipsilateral hemi-diaphragm
Clinical signs of Open PTX (4)
Visible chest wound with air movement through wound sucking/bubbling
Respiraroty distress, tachypnoea, dyspnoea, cyanosis
Diminished or absent breath sound on affected side
PEA arrest
Most are obvious
Signs and diagnosis of massive haemothorax
Early CXR - although 400mls of blood in pleural space before blunting of CP angles
USS useful
CT definitive
Clinical suspicion = chest decompression and ICC
Massive haemothorax volumes over time
Indicative of emergency thoracotomy
> 1500ml blood at insertion
200ml/hr for 3 consecutive hours
100ml/hr for >6hrs
2 types of Flail chest
Central - involving mediastinum
Peripheral - just ribs
Penetrating Cardiac Injury
Percentage of anatomic injury
RV, LV, Mltple chambers, associated coronary artery
RV 43%
LV 34%
One third mixed chambers
5% coronary artery
Beck’s triad
Hypotension
Distended Neck veins
Distant or muffled Heart sounds
Limited clinical use in acute traumatic tamponade
Most common site of aortic injury
Distal to L subclavian origin
Ascending and aortic arch move within cavity, descending and proximal aorta relatively fixed
Greatest shear force at this location
80-90%
Clinical features of aortic injury
Subtle and deceptive (other injuries help mask)
Intrascapular/retrosternal cehst pain
Dyspnoea
Stridor (laryngeal nerve compression)
Dysphagia
Extremity pain (reduced perfusion)
Non specific
Hypertension
Harsh systolic murmur
Swelling at base of neck
CXR findings of traumatic aortic injury (5)
Insensitive
Wide mediastinum >8cm
Indistinct aortic knuckle
Depressed L main bronchus
L apical cap
L sided haemothorax - Chest drain returning arterial blood should raise suspicion
Diagnosis of aortic injury
CT aortogram (highly sensitive)
TOE
Angiography
Mx of aortic injury
Seek and treat other life threats
Make the Dx based on clinical suspicion and CT
Careful regulation of B 100-120 systolic
Definitive - surgical repair and endovascular stenting
Incidence of mortality during aortic surgical repair and endovascular stenting
Incidence of paraplegia
20-30%
5-7%
Tracheobronchial injury prevalence and mortality
Rare occurrence
<3%
10%
Features of tracheobronchial injury
(2)
Wounds open into pleural space -> large PTX fails to improve with ICC -> bronchopleural fistula
Complete transection of tracheobronchial tree with little communication with pleural space
Diagnosis and Mx of tracheobronchial injury
Dx: bronchoscopy
Mx Endotracheal intubation and ventilation, preferably with fibreoptic bronchoscopic technique to visualise passage beyond site of injury without losing airway. Blind placement risks false passage, complete tear conversion
Mx: Surgical repair, thoracotomy
Rib fractures complications
General
Upper
Lower R
Lower L
Mltple
Elderly
Haemothorax/PTX
U 1-3: Protected, severe intrathoracic injury
L 9-12: More mobile, intra abdominal injury
Lower L hepatic
Lower R splenic
Mltple: higher incidence of internal injury
Elderly: 5x mortality
Thoughts on ICC in regards to expected +pressure ventilation or air travel
+ve pressure: Classically taught due to potential to turn small PTX into tension PTX but has been challenged recently
Air travel: literature suggests very rare occurrence
Persistant PTX may indicate (4)
Mx (3)
Misplaced ICC
ICC disconnection
Occluded ICC
Persisting air leak due to pulmonary laceration or tracheobronchial injury
Mx:
Confirm placement - swinging bubbling and ideally CT (XR alone not sufficient)
2nd ICC
Wall suction
Pulmonary contusion
Dx
Mx
Dx: CT, contusion and pneumatoceles
Mx: Supportive Mx with O2 and ultimately ventilation and intubation
Oesophageal rupture
Mechanism (2)
Dx:
Mx:
Blow out
Crush injury
Dx: Gastrograffin oesophagram XR or CT
Upper GI endoscopy
Mx: Early diagnosis paramount, Broad spectrum Abx, Surgical repair
Complications of sternal fractures (3)
Myocardial contusion 1.5-6%
Spinbal fractures <10%
Rib fractures 21% of cases
Surprisingly no association with blunt aortic injury
When to consider resuscitative thoracotomy (4)
Pts with penetrating or blunt thoracic injury with SBP <70
Signs of life within 5minutes
Evidence of tamponade on FAST
When an emergency physician or trauma surgeon with appropriate skills is present
Shock: Definition
Most common type in trauma patients and main priniciple
Clinical condition that involves inadequate blood flow (tissue perfusion) or inadequate oxygen delivery to tissues leading to compensatory physiological changes
Haemorrhagic
Seek source of bleeding and stop it
Haemorrhagic shock
Pathophysiology, effect on preload, compensation
Young patients
Decreased intravascular volume
Reduces flow, BP, preload and afterload, stroke volume
Compensate with vasoconstriction and tachycardia
Young patients can compensate extremely well
Other causes of shock in trauma
Obstructive: Tens PTX, Tamponade
Cardiogenic: Myocardial contusion
Distributive: Neurogenic, unopposed vagal action/ loss of alpha adrenergic tone
Other causes of shock, non traumatic
Obstructive: Emboli - PE, air, amniotic fluid, fat
Cardiogenic: MI, arrythmia, valve lesion rupture
Distributive: Sepsis, anaphylactic shock
Clinical evaluation for shock
(7)
Level of consciousness - allow for TBI, hypoxia, chest injuries
RR: >20 abnormal, again allowing for injuries
CR: Classically taught but wide variations and false findings common, not recommended as part of initial assessment
HR: >100bpm, earliest sign of shock
BP: late sign of shock and complicated by age and pharmacology
Urine output: 0.5ml/kg/hr
Art lines: BP and waveforms
Surrogate markers for shock
Lactate
Acid base status
Pulse pressure in:
Hypovolaemia/cardiogenic shock
Distributive
Narrows
Widens
Minimum expected urine output with units
0.5ml/kg/hr
80kg=40ml/hr
Fibrinogen normal range and targets for trauma patients
2.5-3.0g/L
1.5g/L
Windows on eFAST (4)
Hepatorenal
Spelnorenal
Sub-xiphoid/cardiac
Pelvic
Tourniquet indications
Used if bleeding can not be stemmed with direct pressure
Usually reserved for mangled limbs
Tourniquet time
Elective 2-3 hours
Trauma setting 45-60 minutes
Tourniquet time
Elective 2-3 hours
Trauma setting 45-60 minutes (less than 2 hours)
General principles of tourniquet use (10)
Do not apply over clothing
Do not apply over wounds
Do not apply over joints
Tighten until bleeding stops or until distal pulse is absent
Distal vs proximal arguement ~10-15cm proximal to wound
Side by side may be useful
Tourniquet application prior to shock reduces mortality
Reassessment and tightening usually required
Loosening not performed unless surgical management available
Potential complications of tourniquet use (5)
Ischaemia of distal limb requiring amputation/fasciotomy - not shown to increase amputation (difficult to differentiate due to limb injury)
Nerve palsy - rare ~2%, mostly transient
Thrombosis - rare ~2%, difficult to distinguish
Skin damage/abrasion/bruising/blisters 1-2%
Rhabdomyolysis ~1%
Lethal Triad
Coagulopathy
Acidosis
Hypothermia
What is ATC/TIC
Charachterising mechanisms
Acute traumatic coagulopathy/Trauma induced coagulopathy
Reduced clot strength related to hypofibrin/dysfibrinaemia
Plt dysfunction
Hyperfibrinolysis
Endothelial dysfunction
=Depletion of clotting factors, plt and factor dysfunction, activation of fibrinolysis
Optimal fibrinogen level
Not determined
Some supplement <1.0-1.5g/L
SOme aim for 1.5-2.0g/L
Options for Fibrinogen supplementation
Fibrinogen concentration
FFP 2g/L
Cryoprecipitate 8-16g/L
Fibrinogen 20g/L (not yet licensed in Aus)
What is Thromboelastometry and Rotational Thromboelastometry
TEG and ROTEM
Suspended pin in whole blood sample testing viscosity
ROTEM also can analyzes abnormalities in coagulation pathways
What are the different pathways tested for in ROTEM
Intem - contact acitvation pathway
Extem - tissue factor pathway
Heptem - neutralization of heparin
Fibtem - the contribution of fibrinogen to clot formation
Advantages and disadvantages of ROTEM
(2,3)
Rapid real time results that can detect trauma induced coagulopathy
Allows provision of targeted blood products specific to patient needs
Cost
Maintenance
Interpretation complex
Important consequences of acidosis (3)
Impaired renal perfusion
Decreased cardiac contractility
Reduced adrenocepter responsiveness to inotropes
Important consequences of acidosis (4)
Coagulopathy
Impaired renal perfusion
Decreased cardiac contractility
Reduced adrenoceptor responsiveness to inotropes
Hypothermia effect of coagulation
Decreased enzymatic activity of clotting factors and impairs normal plt function
Damage control objectives (3) - military term
Take all practiable preliminary measures to prevent damage
Minimise and localise damage as it occurs
Accomplish emergency repairs as quickly as possible, restore equipment to operation and care for injured personnel
Damage control resuscitation strategy
Permissive hypotension ~90mmHg without TBI
Haemostatic resuscitation
Damage control surgery
Positive effects of permissive hypotension (3)
Balanced against
Enhanced regional vasoconstriction and clot formation
Reduced risk of iatrogenic hypothermia
Reduced dilutional coagulopathy
Balanced against ischaemic/hypoperfusion effects
Massive transfusion definitions (5)
Replacement of one blood volume in 24hrs
Transfusion of >10 units PRBC in 24hrs
Loss of 50% of blood volume in 4 hrs
Loss of >150ml/minute
Requirement of 4 units PRBC immediately with anticipated ongoing loss
Massive transfusion definition in children
In children, it is defined as transfusion of >40ml/kg (blood volume in children over 1 month old is approx 80ml/kg)
Specs of PRBC
(4)
Volume: 258+-16ml (>220)
Paed volume: 61+-4ml (25-100ml)
Hb: 49+-6g/Unit (>40)
=Raise Hb by ~10g/L
HCT: 0.58+-0.03 (0.50-0.70)
Leukocyte count: 0.26+-0.04x10^6/unit(<1.0)
Options for PRBC in trauma (4)
O-ve: For women of child bearing age to prevent Rh factor incompatibility
O+ve: Immediately available for all other patients
Type specific: ABO and Rh matched, within 10 minutes, Ab incompatibility may exist in this blood
Fully cross matched: Within 60 minutes
*Warmed to 40 degrees
FFP Specs (6)
Volume: 284 ± 13 ml (250–310)
Paediatric volume: 70 ± 3 ml (60–80)
Platelet Count: 8 ± 4 x 10^9/L (< 50)
Leucocyte Count: 0.04 ± 0.04 10^9/L (< 0.1)
Factor VIIIc: 1.05 ± 0.16 IU/mL (> 0.70)
Dose: in trauma 1:1:1, reversal of Warfarin is 10-15ml/kg ~700-1050ml=3-4 units
Platelet specs
Platelet Irradiated Apheresis Leucocyte Depleted
Volume: 181 ± 11 ml (100–400)
Paediatric volume: 51 ± 2 ml (40-60)
Platelet count: 280 ± 37 10^9/unit(> 200 to < 510)
pH: 6.9 ± 0.2 (6.4–7.4)
Leucocyte count: 0.20 ± 0.11 10^6/unit (< 1.0)
Platelet Irradiated Pooled Leucocyte Depleted
Volume: 334 ± 14 ml (> 160)
Platelet count: 269 ± 37 10^9/unit (> 240)
pH: 7.0 ± 0.1 (6.4–7.4)
Leucocyte count: 10^6/unit 0.33 ± 0.01 10^6/unit (< 0.8)
NB: “Pooled” platelets are combined from up to 4 ABO identical donors
Cryoprecipitate Facts
The fibrinogen level in cryoprecipitate is 4-8 times that of FFP
Fibrinogen is essential for coagulation due to its role in initial platelet aggregation and formation of stable fibrin clot
Fibrinogen levels should be maintained at least > 1.0g/L, and ideally > 1.5 g/L
Cryoprecipitate is commonly needed in addition to FFP to maintain adequate fibrinogen levels during massive transfusion
Prediction of massive transfusion scores (2)
ABC Score Sens 46% Specificity 94%
TASH Score Sens 25% Specificity 99%
ABC Score
Assessment of blood consumption score
ED Sys BP <90mmHg 0/1
ED HR >120bpm
Penetrating mechanism
+ve fluid of FAST exam
A score of 3 predicts 45% need for massive transfusion; score of 4 predicts 100%
TASH
Trauma associated severe haemorrhage
Systolic BP <100mmHG
HR >120
Hb <7g/dl
+ve FAST with haemodynamic instability
Complex long bone +/or pelvic fracture
Base Excess <-10mmol/L
INR >1.5 during resus
Impacts in MVA (3)
Vehicle impact
Body impact - Windshield/steering wheel/dashboard
Organ impact
WIndshield damage suspected injuries (4)
Intracranial bleed
Skull fracture
Facial injuries
C-spine injury
Steering wheel damage suspected injuries (7)
Laryngeal and tracheal injury
Sternal fracture
Myocardial contusion
Pericardial tamponade
Flail chest
Pneumothorax/haemothorax
Abdominal Injury - solid organ, hollow viscus
Dashboard damage suspected injuries (3)
Knee
Pelvic girdle
Head and c-spine
Ejected occupants
More severe injuries
Higher morbidity and mortality
Potential severe multi-system trauma
Spinal trauma more common
Motorcycle accidents suspected injuries
Most deaths 2ry to severe TBI
Severe multi system trauma
Similar to pattern of ejected occupants
Pedestrian vs car suspected injuries with impacts (3)
1st impact - lower extremity hit by bumper
2nd impact - upper legs, trunk hit by hood of car
3rd impact - head injury as patients hits ground, usually head first
*In children 2nd impact involves abdomen and thorax
Cyclist suspected handlebar injuries (4)
Spleen and liver lac
Hollow viscus perf
Pancreatic injury
Duodenal haematoma
Vertical deceleration injury severity dependent on (3)
Distance of fall
Typer of surface landed on
Area of body that impacts first
Vertical deceleration suspected injuries (5)
Multi system
Extremity - lower and upper limb
Pelvic girdle, hip, femur, acetabulum
Spine - lumbar and sacral
Head
