Severe injury

Trauma,
severe injury
dr. Péter Kanizsai
Semmelweis University , Dept. of Anaesthesia and
Intensive Care
Division of Oxyology and Emergency Medicine
What is severe injury?
•
•
•
•
Severe injury :
a significant acquired brain injury,
paraplegia, quadriplegia, amputation of
a limb or burns to more that 50 percent
of the body; or
any other injury specified by the
regulations for the purposes of this
definition
The following injuries (have
been prescribed by regulation) as severe
injuries:
– permanent blindness
– burns to not more than 50 percent of the
body that cause severe disfigurement and
comprise of full thickness burns:
•
•
to the head, neck, arms or lower legs; or
that result in severe difficulties in performing
mobility, communication and self care tasks
– a brachial plexus injury that results in the
loss of the use of a limb
How can we tell it is „severe” ?
Revised Trauma Score (RTS)
Injury Severity Score (ISS)
Coded
Value
GCS
SBP
(mm
Hg)
RR
(breaths
/min)
Glasgow
Coma
Scale
(GCS)
Systolic
Blood
Pressure
(SBP)
Respiratory
Rate
(RR)
Coded
Value
0
3
0
0
13-15
>89
10-29
4
1
4-5
< 50
<5
9-12
76-89
>29
3
2
6-8
50-75
5-9
3
9-12
76-90
>30
6-8
50-75
6-9
2
4
13-15
>90
10-30
4-5
1-49
1-5
1
3
0
0
0
RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR
TRISS
Trauma Score - Injury Severity Score : TRISS
TRISS determines the probability of survival (Ps) of a
patient from the ISS and RTS using the following formulae:
Where 'b' is calculated from:
http://www.trauma.org/archive/scores/triss.html
Trauma facts
• Epidemiology
– Leading cause of death in the first 4 decades
– 150,000 deaths annually in the US
– mortality ≈ 17 % in Europe
– Permanent disability 3 times the mortality rate
– Trauma related dollar costs exceed $400 billion
annually
Trimodal (classic) death distribution
Courtesy of dr. Z. Pető, University of Szeged
Bimodal death distribution
The Nebraska experience, 1976
Organizational aspects
Improved resuscitation/critical care
A –advanced
T – trauma
L – life
S - support
The ATLS Concept
 ABCDE approach to evaluation and treatment
 Treat greatest threat to life first
 Definitive diagnosis not immediately
important
 Time is of essence
 Do no further harm
 Good recordkeeping is of paramonunt!
ATLS Concept
Airway with c-spine protection
Breathing / ventilation / oxygenation
Circulation:
stop the bleeding!
Disability / neurological status
Expose / Environment / body temperature
The trauma team
• An effective trauma system needs the
teamwork of EMS, emergency medicine,
trauma surgery, and surgery subspecialists
• Trauma roles
– Trauma captain
– Interventionalists
– Nurses
– Recorder
Trauma Team
Initial Assessment / Management
Injury
Primary Survey
Transfer
Optimize
patient status
Adjuncts
Resuscitation
Re-evaluation
Re-evaluation
Detailed
Secondary Survey
Adjuncts
Courtesy of dr. Z. Pető, University of Szeged
Initial assessment
– organizational aspects (time dependent team work)
– always seek info on
•
•
•
•
the mechanism of injury
any death in the same compartment
high velocity collision
ejection
– vital signs
– prioritize
– primary survey and initial stabilization are
simultaneous activities!
Quick Assessment
What is a quick, simple way
to assess a patient in 10 seconds?
● Identify yourself
● Ask the patient his or her name
● Ask the patient what happened
Courtesy of dr. Z. Pető, University of Szeged
Methods of primary survey
• Physical examination – look, listen and feel
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–
–
–
–
BP
HR
SpO2
CRT
temperature
• PoC techniques:
– ABG analysis
– FAST
– CXR, C-spine
• Imaging
– CT
– MR
Focused Assessment with Sonography in Trauma
FAST
FAST
Systematic approach
A – airways with cervical spine protection
– First you'll need to judge if the
airway patent?
• Have the patient speak to you to
establish patency and to evaluate for
voice change and stridor
• Is there evidence of pooling
secretions or cyanosis?
– If airway is intact: look for
problems which may cause the
patient to lose that airway in the
near future.
• facial injury causing obstruction or
bleeding
• laryngeal fractures
• expanding hematomas
• GCS of 9 or less requires intubation
Systematic approach
B - breathing
•
Inspect: look for
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–
–
–
–
•
cyanosis,
JVD (tension pneumothorax or cardiac tamponade)
symmetric movement of the chest (flail chest)
accessory muscle use (tension pneumothorax)
open chest wounds (open pneumothroax).
Ausculate: listen for
– stridor (upper airway injury),
– lung breath sounds (pneumo or hemothorax)
•
Percuss: feel for:
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–
–
–
–
–
hyper-resonance (pneumothorax)
dullness (hemothorax, FAST)
subcutaneous emphysema (airway injury)
paradoxical movements (flail chest)
crepitation & point tendnerness(rib fractures)
bruising (pulmonary contusion).
Systematic approach
C- Circulation
• Hemorrhage should be assumed in any
hypotensive trauma patient
• Rapid assessment of hemodynamic status
– Level of consciousness
– Skin color
– Pulses in four extremities
– Blood pressure and pulse pressure
Systematic approach
Circulation Interventions
• Cardiac monitor
• Apply pressure to sites of external hemorrhage
• Establish IV access
– 2 large bore IVs
– Central lines if indicated
• Cardiac tamponade decompression if indicated (FAST)
• Volume resuscitation
– Have blood ready if needed
– Level One infusers available
– Foley catheter to monitor resuscitation
Systematic approach
C - circulation
• Feel for pulses.
– as a rule of thumb:
• if a radial pulse is palpable, it suggests a systolic blood pressure of
at least 80 mm Hg.
• if the femoral or carotid are palpable, these suggest a systolic
blood pressure of at least 60 mm Hg.
• Most patients will have a tachycardic response.
– exceptions:
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•
•
•
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Neurogenic shock to sympathetic cord disruption
Beta blockade,
Calcium channel blockade
Elderly
Children and young adults
Conditioned athletes start with a lower basal level.
Systematic approach
C - circulation
ATLS Classification of hemorrhagic shock
Heart
Rate
Blood
Findings
Pressure
Blood
Loss
Treatment
Class I
Normalfast
Normal
<15%
Normal
Saline
Class II
Normalfast
Normallow
Narrowed
Pulse
Pressure
15 30%
Normal
Saline
Class III
Fast
Low
Altered
30 Mentation 40%
NS + Blood
Class IV
Fast
Low
Obtunded >40%
NS + Blood
Systematic approach
D - disability
• Quick assessment of mental status via the AVPU scale:
– Alert - a fully awake patient.
– Voice - the patient responds when verbally addressed. Response to
voice can be verbal, motor, or with eyes.
– Pain - the patient makes a response on any of the three component
measures only when pain stimulus is delivered.
– Unresponsive - If the patient does not give any eye, voice or motor
response to voice or painful stimuli.
• Perform a gross motor/sensory examination to determine if CNS is
intact.
• Assess pupils for size, symmetry and reactivity.
• The Glascow Coma Score (GCS) evaluates mental status via
assessment of eye opening, motor response, verbal response. (best
possible :15, worst possible:3)
Disability
Interventions
• Spinal cord injury
– High dose steroids if within 8 hours not
recommended any more!
• ICP monitor- Neurosurgical consultation
• Elevated ICP
– Head of bed elevated
– Mannitol
– Hyperventilation
– Emergent decompression
Consider Early Transfer
● Use time before
transfer for
resuscitation !
● Do not delay transfer
for diagnostic tests !
What is the secondary survey?
The complete
history and
physical
examination
Secondary survey
1. Head, eyes, ears, nose, and throat (HEENT)
a. Assess for evidence of a basilar skull fracture by identifying the presence of
Battle’s sign (ecchymosis over the mastoid), raccoon eyes (ecchymosis around
the eyes) or hemotympanum (blood behind the eardrum)
Look for a cerebrospinal fluid (CSF) leak :rhinorrhea or otorrhea.
b. Assess for depressed skull fractures by careful palpation. Do not fiddle with
foreign bodies and bone fragments !
c. Assess for facial injury and stability by palpating the facial bones. Severe
fractures carry the risk of airway occlusion! Malocclusion of the teeth may
indicate a mandible fracture.
d. Look for lacerations that will require repair. Scalp lacerations can bleed
vigorously.
e. Determine visual acuity and assess pupillary size and function.
f. Examine the nasal septum for a hematoma!
Secondary survey
2. Cervical spine/neck
a. Palpate the cervical spine and identify areas of tenderness, swelling or step-off
deformity.
b. Look for penetrating injuries within the neck.
c. Evaluate for subcutaneous emphysema, which may be associated with laryngotracheal
injury or pneumothorax.
3. Chest
a. Palpate the sternum, clavicles, and ribs
for tenderness or crepitus. The presence of subcutaneous emphysema suggests an
underlying pneumothorax.
b. Look for bruising or deformity to suggest an injury to the underlying lung
Secondary survey
4. Abdomen
a. Assess for any distention, tenderness, rebound or guarding. Watch for injuries
to the liver and spleen.
b. Flank ecchymosis may suggest a retroperitoneal bleed.
c. The presence of a “seat belt sign” is correlated with an eight-fold higher relative
risk of intraperitoneal injury
d. Reliable assessment of the abdomen may be compromised (altered mental
status, intoxication with alcohol or illicit drugs, or the presence of
painful distracting injuries.
5. Back
a. Log roll the patient with assistance while maintaining spinal alignment. Palpate
the entire spine for any spinous process
tenderness.
b. Assess for hidden wounds in the axilla, under the cervical collar, and in the
gluteal region.
Secondary survey
6. Pelvis
a. In order to assess the stability of the pelvis gently employed anterior–posterior
compression of the anterior superior iliac spines, lateral compression of iliac crests, and
cranial–caudal distraction of opposite iliac crests. This should be performed
one time only!
b. Palpate the symphysis pubis for pain, crepitus, or widening.
c. Pelvic fractures can be responsible for as much as 2 -4 L of occult blood loss.
7. Perineum
a. Evaluate the perineum for ecchymosis (pelvic fracture or urethral disruption.)
8. Urethra
a. Look for blood at the urethral meatus to assess for possible urethral disruption
before placing a urinary catheter.
Always inspect the back!
Secondary survey
9. Extremity examination
a. Re-check the vascular status of each extremity, including pulses, color, capillary refill,
and temperature.
b. Inspect every inch, palpate every bone, and check the range of motion of all joints.
Assess for deformity, crepitus, tenderness, swelling, and lacerations.
c. Unstable fractures or those associated with neurovascular compromise should
be reduced immediately. (hemostasis, preventing further injury, and enhancing patient
comfort).
10. Neurologic
a. At this time, a complete neurologic examination should be done:
- repeat GCS score
- reevaluation of the pupils
- a cranial nerve examination
- a complete sensory and motor examination
- testing of the deep tendon reflexes
- assessment of the response to plantar stimulation.
Airway management
Aim: secure and permanent airway
intubation
surgical
Why do patients die despite all our
efforts?
What causes delayed trauma
mortality?
Infection
• Complications
– Frequent COD in pts who survive longer than 3
days.
– Immune system is frequently depressed because
of physiological response or treatment
– Accidents take place in dirty environment
http://www.defrance.org/cgiscript/CSUpload/CSUpload.cgi?database=PPT.db&command=viewone
&id=10&rnd=75.52697413983372
Acute Respiratory Distress
• Inflammatory syndrome-disrupts the alveolarcapillary membrane
– The permeability increases and proteins/fluid shift
into the interstitial space
– A cascading failure begins that eventually leads to
alveolar collapse
http://www.defrance.org/cgiscript/CSUpload/CSUpload.cgi?database=PPT.db&command=viewone
&id=10&rnd=75.52697413983372
Systemic Inflammatory Response
• Inflammation is a normal defensive response
to insult/injury
– Creates a lethal microenvironment
– Vascular system shunts elements to area
• Leukocytes
• Plasma proteins
• platelets
http://www.defrance.org/cgiscript/CSUpload/CSUpload.cgi?database=PPT.db&command=viewone
&id=10&rnd=75.52697413983372
Systemic Inflammatory Response
• Local inflammation is generally self limiting (810 days)
• Systemic
– Organs remote from insult show signs
• Temperature abnormalities
• Tachycardia
• Ventilation abnormalities
http://www.defrance.org/cgiscript/CSUpload/CSUpload.cgi?database=PPT.db&command=viewone
&id=10&rnd=75.52697413983372
Multi Organ Dysfunction Syndrome
• 7%-15% of critically ill patients suffer failure of
at least two organ systems
• Failure of three or more organ systems leads
to a 90%-95% mortality rate
• Trauma patients are very susceptible to
– Prolonged circulatory shock
http://www.defrance.org/cgi– Tissue hypoxemia
script/CSUpload/CSUpload.cgi?database=PPT.db&command=viewone
&id=10&rnd=75.52697413983372
– Infection
MODS
• Either primary or secondary
• Results from acute immune and inflammatory
response
– Chemistry is complicated
– The immune system turns on normal cells and
destroys them
http://www.defrance.org/cgiscript/CSUpload/CSUpload.cgi?database=PPT.db&command=viewone
&id=10&rnd=75.52697413983372
Myoglobinuria
• Trauma causes increased breakdown of
skeletal muscles
– the muscle releases myoglobin and potassium
– myoglobin is a large molecule that blocks the renal
tubules  kidney failure
http://www.defrance.org/cgiscript/CSUpload/CSUpload.cgi?database=PPT.db&command=viewone
&id=10&rnd=75.52697413983372
DIC
• Initially hypercoagulation– leading to organ
ischemia.
• Simultaneous micro vascular hemorrhage and
clotting
– Clotting agents are consumed faster than created
• Most likely results from damage to the endothelium
• Results in uncontrolled bleeding additional to the
blood loss due to the initial insult
http://www.defrance.org/cgiscript/CSUpload/CSUpload.cgi?database=PPT.db&command=viewone
&id=10&rnd=75.52697413983372
All the above will
lead to
HYPOVOLAEMIC
SHOCK !
What is shock?
Generalized State of Hypoperfusion
Inadequate oxygen delivery
Catecholamines and other responses
Anaerobic metabolism
Cellular dysfunction
Cell death
Courtesy of dr. Z. Pető, University of Szeged
Signs of shock
● Alteration in level of consciousness, anxiety
● Cold, diaphoretic skin
● Tachycardia
● Tachypnea, shallow respirations
● Hypotension
● Decreased urinary output
Courtesy of dr. Z. Pető, University of Szeged
Interventions
Direct pressure /
tourniquet
Reduce
pelvic
volume
Angioembolization
STOP
the
bleeding!
Splint
fractures
Operation
Courtesy of dr. Z. Pető, University of Szeged
The IT clamp
● Fluid resuscitation
● Vascular access?
● Type?
● Volume?
● Monitor response
● Prevent hypothermia!
Vascular access?
F=
ΔP x π x r4
8η x l
Type? Volume?
Aim is to restore circulation
-team approach
-no benefit of colloid over crystalloid
-give 2 litres of crystalloid initially (N.S.)
-blood sample for serology, clotting screen
-to keep Hb>80 g/l cell saver techniques are required
-2 units of 0 neg blood can be transfused in emergency
-always try to transfuse fully compatible bloodaim to a PLT count
> 75 G/l and TT < 1,5
-if 1-1,5 blood volume was repleted give FFP and PLT complex
-keep calcium > 1,13 mM/l and fibrinogen > 1 g/l
-prevent DIC
-New guidelines suggest use of 1-1-1 (1 unit of PBC, 1 unit of FFP
and 1 unit of platelet)
General emergency remarks
• Time dependency:
– Golden hour (?)
• Not scientifically supported
• But it’s a good rule of thumb
• Definitive care is the answer- not field care
General emergency remarks
• Allocation
– care is allocated to patient
– transfer only if unavoidable
– prioritize according to severity
General emergency remarks
• Integration
– multidisciplinary approach
– in trauma care there is no „I”,
only „we”
– consultation and referral 24/7
Now let’s go and operate!
Fractures need mended!
Save the patients life with quick and
extended operations!
But what if…
•
•
•
•
patient is too old?
patient is exsanguinated?
patient is hypothermic?
patient is haemodynamically
unstable?
• etc..
A new paradigm
Damage control
Definitive care vs. damage control
- 1970-1989 early total care
- 1990 borderline era
- 2000 – damage control
In a timely fashion…
• Most patients are „not ready” for intervention
• Long operations will result in large fluid and
heat loss
• Not all „threatening injuries” are real threat to
life
• Surgeons need self control
Vicious circle in major torso trauma
KC Sihler, LM Napolitano : Massive Transfusion New Insights Chest, 2009; 36
Damage control
Choosing the right candidate
- hypothermia: T<34 °C
– acidosis pH < 7,2
– lactate > 5 mmol/l
– coagulopathy
– SBP < 70 Hgmm
– Transfusion > 15 units
– ISS > 36
Practice of damage control
Practice of damage control
Priorities in the multiple injured victim
Save life
- Resuscitation, ATLS
(advanced trauma life support)
e.g. chest drain, amputation, laparotomy
Save limb
- Revascularization
- Fasciotomy
Save fracture
- Debridement
- Reposition, stabilization, „alignement”
Take home messages
• Trauma is best managed by a team approach
• Importance of ATLS
• A thorough primary and secondary survey is
key to identify life threatening injuries
• Once a life threatening injury is discovered,
intervention should not be delayed
• Disposition is determined by the patient’s
condition as well as available resources.