Trauma Flashcards
Massive haemorrhage protocol
Multi-disciplinary protocol for delivering large volumes of balanced transfusion products to treat massive haemorrhage. Used in trauma, but also in massive medical or surgical bleeding.
Multiple different definitions, however I use replacement of 1 blood volume in 6 hours, or half a blood volume in 1 hour
Initial pack is 2g TXA and 2 RBC + 2 FFP (trauma)
2nd box is 4RBC, 4FFP and 3 cryo
3rd box is 4 RBC, 4FFP, 1 platelet
Alternate between box 2 and 3 until bleeding slowed
Monitor bloods every 30 mins - VBG, Ca, FBC, TEG or coags and fibrinogen.
Give 1g calcium with every box
What are the stages of hypovolaemic shock
4 stages of haemorrhagic shock based on degree of blood loss. RR most sensitive parameter, with BP not having significant changes until stage 3-4
Class 1: Blood loss < 15%. HR<100. Normal PP and BP. RR 14-20
Class 2: Blood loss15-30%. HR> 100. Normal BP. RR 20-30.
Class 3: Blood loss 30-40%. HR > 120. BP decreased. Narrow PP. RR 30-40.
Class 4: Blood loss > 40%. HR>140. BP decreased. PP narrow. RR >35
Indications for resuscitative thoracotomy
Penetrating trauma with PEA arrest (Release tamponade, clamp aorta or lung hilum)
Concern for massive lower body exsanguination with witnessed arrest - for cross clamping aorta
Pathophysiology of trauma
Ebb phase
- severe shock with tissue hypoxia, oxygen consumption
- Hypovolaemia causes release of catecholamines which trigger neuroendocrine response
- Anaerobic metabolism leads to lactate accumulation
Flow phase where restoration of oxygen transport is restored and metabolic changes occur (initially catabolic then anabolic)
- Tissue injury releases inflammatory mediators
- inflammatory response mediated by cytokines, complement, prostaglandins and leukotrienes
- Free radicals produced
- Activation of sympathetic adrenal axis
- Hyperdynamic state
Zones of the neck and exploration
Zone 1 - sternal notch to lower border of cricoid cartilage. CTA helpful. Explore properly with median sternotomy, or possibly supraclavicular or infraclavicular approach.
Zone 2 - From cricoid cartilage to angle of mandible. Explore if platysma breached or if hard signs of vascular compromise
Zone 3 - From angle of mandible to base of skull. CTA and IR intervention may be more appropriate here
Types of injury in blast injury
Primary: Barotrauma to air: fluid interface
Secondary: Struck by projectiles. Blunt or penetrating injuries
Tertiary: Displacement or crush injuries from being thrown by the blast or having building crush you
Quaternery: Burns, asphyxia or toxic inhalation
Quinery (controversial): Hyperinflammatory state or exposure to toxins or materials used in a bomb (eg radiation exposure)
Liver injury grading
Grade 1:
Laceration < 1cm depth or subcapsular haematoma < 10% SA
Grade 2:
Lac 1-3cm deep or subcapsular haematoma 10-50% SA or intraparenchymal haematoma < 10cm diameter
Grade 3: Laceration > 3cm deep or subcapsular haematoma > 50% SA or intraparenchymal haematoma > 10cm diameter or active bleeding within parenchyma
Grade 4: 25-75% lobe disruption or active bleed into the peritoneum
Grade 5: Parenchymal disruption > 75% of a lobe or juxtahepatic venous injury (caval or central hepatic vein)
Pancreas grading system
Grade 1:
Superficial lac or minor contusion without duct injury
Grade 2: Major lac or contusion without duct injury or tissue loss
Grade 3: Distal transection or parenchymal injury without duct injury
Grade 4: Proximal transection or parenchymal injury involving the ampulla
Grade 5: Massive disruption of the head
Splenic injury grading
Grade 1:
Lac < 1cm deep or subcapsular haematoma < 10%
Grade 2:
Lac 1-3 cm or subcapsular haematoma 10-50% SA or intraparenchymal haematoma > 5cm
Grade 3:
Lac > 3cm or subcapsular haematoma > 50% or ruptured haematoma
Grade 4:
Segmental or hilar vessel bleed within the capsule or > 25% of spleen devascularised
Grade 5:
Hilar injury with bleeding into the peritoneum or shattered spleen
Kidney injury grading
Grade 1:
Subcapsular or parenchymal haematoma without laceration
Grade 2:
LAc < 1cm without urine extravasation or perirenal haematoma confined to GErotas
Grade 3:
Lac > 1cm without urine extravasation or active bleeding contained within Gerotas
Grade 4:
Lac into collecting system with urine extravasation or segmental vessel injury with bleeding outside Gerotas, or thrombosis of renal vessel with infarction of kidney without bleeding
Grade 5:
Shattered kidney or pelviureteric injury/ avulsion or main hilar disruption with devascularised kidney and active bleeding
Diaphragm injury
Grade 1:
Contusion
Grade 2:
Lac <2cm
Grade 3:
Lac 2-10cm
Grade 4:
Lac > 10cm with tissue loss < 25cm2
Grade 5:
Lac with tissue loss > 25cm2
Principles of damage control resuscitation
- Minimise time in scene and ED with expedited trip to OR
- RSI intubation and induction of anaesthesia
- Early rewarming
- Permissive hypotension
- Avoidance of crystalloid fluids (worsens acidemia and coagulopathy)
- Balanced blood product transfusion - MTP
Goals of damage control surgery
Drain
Divert
Defunction
Debride
Control of haemorrhage
Phases of damage control
phase 0: ED
- Early rewarming
- MTP 1:1:1 and manage coagulopathy
- Avoid IV crytalloid
- Permissive hypotension
- RSI and intubation
- Expedited transfer to OT
Phase 1: Damage control surgery
- Divert
- Drain
- Debride
- Defunction
- Control haemorrhage
- Laparostomy
Phase 2: ICU
- Correct coagulopathy
- Warm patient
- Correct acidosis
- Complete primary and secondary survery
- Imaging
Phase 3: Planned relook for definitive management
- Remove packs
- Definitive repair, anastamosis, stoma
- Assess for missed injuries
Phase 4: Closure of abdomen
TEG components
Risky kids are massive liabilities
- R time: Time to start forming clot. Coag factors def. FFP
- K time: Time for clot to reach strength. Fibrinogen. Cryo.
- Alpha angle: Rate of fibrin accumulation. Fibrinogen. Cryo
- Max amplitude: Measure of platelet function. Platelets
- Lysis: Measure of fibrinolysis. Tx with TXA
