Trauma 1
When to remove C-Collar?
ASAP
C‐collars are associated with decubitus ulcers, raised ICP, pneumonia, and delirium, and leading to increased ICU and hospital length of stay, so whenever possible, clear the C‐spines of patients
laparotomy indication in blunt injury!
Unstable vital signs with strongly
suspected abdominal injury
Unequivocal peritoneal irritation
Pneumoperitoneum
Evidence of diaphragmatic injury
Significant gastrointestinal bleeding
C-collar in the intubated patient!
CT scan is completely normal, i.e. no bony fractures and no soft tissue abnormalities, realizing that if ligamentous injuries are missed, they should become obvious when the patient regains consciousness and can then be re‐examined, after which a flexion‐extension views x‐rays or MRI can be considered
CT insertion site?
safe triangle!
central vs peripheral line in trauma?
Vascular access – 2 large‐bore antecubital peripheral IVs are enough in most cases, and in severely injured patients a femoral cordis may be considered.
the femoral vein is the location of choice
Young‐Burgess classification of pelvis fractures!
1:1:1 Transfusions
PROMMTT Study: decreased 6h mortality with an increased ratio of plasma: RBC and RBC: platelets.
In the first 6h, patients with ratios less than 1:2 were 3-4 times more likely to die than patients with ratios of 1:1 or higher. Identifying patients who may require activation of a massive transfusion protocol:
Hsu, 2013
Signs of vascular injury in penetrating trauma!
US vs. CXR in PTX!
bedside ultrasound has higher sensitivity for detection of pneumothoraces than supine CXR (98% versus 75%) when compared to a gold standard of CT scan
laparotomy indication in penetrating injury!
Hemodynamic instability
Peritoneal signs
Evisceration
Diaphragmatic injury
Gastrointestinal
hemorrhage
Implement in situ
Intraperitoneal air
Damage control resuscitation!
1. Hypotension disproportionate to the suspected injury
2. Hypotension unresponsive to rapid fluid resuscitation
3. Massive hemothorax unresponsive to thoracostomy and
fluid resuscitation
4. Persistent metabolic acidosis
5. The presence of pericardial effusion on echocardiography or elevation of CVP and neck veins with continuing hypotension despite fluid resuscitation
REBOA
A meta-analysis of REBOA vs cross-clamping the aorta in resuscitative thoracotomy performed showed that the odds of mortality were no differences between the two groups but sensitivity analysis showed that the mortality risk was significantly lower in those undergoing REBOA.
Manzano,WJES. 2017
SCRAP Rule ?
Indications for chest CT in blunt trauma .
A retrospective study of 434 patients with GSC >8 , ISS score >12, all had CT at admission.
The rule consists of: S(saturation) C(CXR) R(Resp Rate) A(Auscultation of chest) P(Palpation of chest).
If O2 sat normal (95% RA or 98% with supplemental O2), normal or unchanged CXR, RR =<25, Chest auscultation normal, Palpation of chest normal = 100% sensitivity and NPV for major thoracic injuries.
Payrastre, 2012
Bicarb in Trauma patient with acidosis!
A retrospective study of 225 severely acidotic trauma patients, with a pH less than 7.10.
Bicarbonate increased HCO3- and PaCO2.
PaCO2 rise was associated with increased risk of mortality.
In the acidotic patient, fluid resuscitation, initiating massive transfusion protocols if necessary, and transfer to OR/angio continue to be the most important resuscitative measures.
Wilson et al, J Trauma Acute Care Surg. 2013
which trauma patients are the sickest?
1- one drop in SBP
2- Base Deficit (BD), Lactate, Hematocrit
3- crump factors" SBP <105 and FAST positive and BD >-6… consider no CT & direct to OR"
4-serial lactate
5-Flat IVC on CT or in US, is an independent predictor of mortality
normal saline vs. RL in trauma
no difference in mortality in the choice of initial fluid for trauma: normal saline vs. Ringer’s lactate
what are TRAINS?
Traumatic Aortic INjury Score) Predicting aortic injury in trauma:
- Widened mediastinum (4 pt)
- BP < 90 (2 pt) - Long bone fracture (2 pt)
- Pulmonary contusion (1 pt)
- Left scapular fracture (1 pt)
- Hemothorax (1 pt)
- Pelvis fracture (1 pt)
Score >= 4 high risk Not a very sensitive but specific score
Pan CT scanning vs. selective scanning?
pros vs cons
- In patients with polytrauma or unreliable history and exam, WBCT should be utilized.
– Patients who are evaluable through history and exam with focal trauma should undergo selective imaging.
TBI outcome predictors?
1- GCS
Although a low-GCS score on admission does not necessarily predict a poor neurological outcome, GCS assessment 15 days after the injury is a strong predictor of outcome and mortality risk. Indeed, several studies showed that a low initial GCS (3/15) is related to an almost 50% survival rates and a 13.2% good neurological outcome.
2- Pupil size
Pupil size and response proved to be stronger predicting factors of mortality than motor response, since almost 80% of patients with bilaterally fixed dilated pupils, eventually died.
J Neurosurg. 2017
Mannitol vs hypertonic saline!
TBI
both can be used,
Mannitol is a potent diuretic which may increase the risk of kidney injury in hypovolemic patients. While mannitol induces an osmotic diuresis, the initial rapid increase in intravascular volume can paradoxically cause acute hypervolemia (which could precipitate heart failure or pulmonary edema in susceptible patients)
HTS can cause a rapid increase in serum sodium concentrations, raising concern for central pontine myelinolysis.HTS is a volume expander, which could precipitate volume overload.
for refractory intracranial hypertension, hypertonic saline seems to be preferred.
Vasopressors in Trauma!
yes or no?
Critical Care Practice Committee of the Association of Emergency Physicians, recommendations for the use of vasopressors and inotropes in various shock states were given.[38] It was suggested that vasopressin may be administered in hemorrhagic shock if deemed necessary; however, routine use of vasopressor was not recommended.
Although vasopressors may have beneficial effects in the resuscitation of hemorrhagic shock, one should not undermine the fact that balanced fluid resuscitation and blood product administration remain the first priority in the management of hemorrhagic shock. Thus, vasopressor administration in the absence of adequate volume resuscitation may, in fact, worsen the outcome by increasing mortality
Vasopressor and inotrope use in Canadian Emergency Departments: Evidence-based consensus guidelines. CJEM 2015;17
Mortality predictors for trauma patients!
Trauma Early Mortality Prediction Tool
Age (years)≥59.50, SBP (mm Hg)≥163.50, Creatinine (mg/dL)≥1.35, INR≥1.25, PTT (s)≥31.40, Hemoglobin (g/dL)≤12.75, Platelets (103/µL)≤224.50, Base excess (mmol/L)≤−4.35, Temperature (°C)≤36.25
Trauma Injury Severity score (2009)
Trauma Injury Severity Score (1994)
Revised Trauma Score
GCS
ISS
What is TASH?
Trauma Associated Severe Hemorrhage Score (TASH-Score, 0-28 points)
SBP (<100 mm Hg=4 pts, <120 mm Hg=1 pt)
hemoglobin (<7 g/dL=8 pts, <9 g/dL=6 pts, <10 g/dL=4 pts, <11 g/dL=3 pts, and <12 g/dL=2 pts)
intra-abdominal fluid (3 pts)
complex long bone and/or pelvic fractures (AIS 3/4=3 pts and AIS 5=6 pts),
heart rate (>120=2 pts),
base excess (<-10 mmol/L=4 pts, <-6 mmol/L=3 pts, and <-2 mmol/L=1 pt),
gender (male=1 pt)
CPR in Traumatic Cardiac Arrest?
H – Control of external hemorrhage, splint pelvis/fractures, gaining access and volume resuscitation…. preferably central access ABOVE the diaphragm (i.e. a subclavian central line) and immediate resuscitation with blood products
O – Basic and advanced airway management, maximize oxygenation
T – Decompress the chest with finger or tube thoracostomies, we should stay away from needle decompression
T – Evaluate for tamponade with ultrasound and address tamponade with pericardiocentesis or thoracotomy