Trauma: The Golden Hour Dennis Kim md frcs(C)

5. Hemorrhagic shock is usually caused by bleeding into or from:

• A) abdomen

• B) pelvis

• C) chest

• D) head

• E) all of the above

• F) A,B,C

The Golden Hour

• Shock Pathophysiology

• inadequate organ perfusion and tissue oxygenation

• 3 factors determine:

• 1. oxygen content

• 2. oxygen delivery

• 3. distribution

The Golden Hour

• Shock Pathophysiology

• prolonged hypoperfusion creates a vicious cycle of ischemia and shock

• 2 most important steps in managing shock:

• 1. recognition

• 2. treatment

The Golden Hour

• Rapid Resuscitation

• restores circulating volume

• improves oxygen delivery

• prevents cellular ischemia and tissue necrosis

• prevents onset of secondary cellular injury

• prevents onset of MODS

The Golden Hour

• What should we be doing?

• Rapid assessment

• Resuscitation and stabilization

• Definitive management/Transfer

ATLS Overview

• The ATLS Concept

• Primary Survey

• Adjuncts

• Secondary Survey

• Definitive Care/Transfer

ATLS Overview

• The ATLS Concept

• treat life threatening injuries as they are identified

• assessment/diagnosis and resuscitation are simultaneous

ATLS Overview

• Primary Survey

• A Airway

• B Breathing

• C Circulation

• D (neurologic) Disability

• E Exposure / Environment

• AMPLE

ATLS Overview

• Adjuncts

• Urinary catheter

• NG tube

• Xrays

ATLS Overview

• Secondary Survey

• Thorough “head to toe” assessment

• Definitive Care/Transfer

Deadly Dozen

• Lethal Six

• airway obstruction
• tension PTX
• open PTX
• flail chest
• massive hemothorax
• cardiac tamponade

ATLS Specifics

• A - airway (with C-spine protection)

• Preventable Deaths from Airway Problems

• failure to recognize need for airway
• inability to establish airway
• failure to recognize incorrect placement
• displacement of previously placed airway
• failure to recognize need for ventilation
• aspiration of gastric contents

Airway Algorithm

ATLS Specifics

• A - airway (with C-spine protection)

• Rapid Sequence Intubation (RSI)

• preoxygenation
• cricoid pressure
• sedation (etomidate, midazolam)
• succhinylcholine
• orotracheal intubation
• cuff inflation, confirmation of position
• release of cricoid pressure

ATLS Specifics

• Alternative Airway Devices/Options

• nasotracheal intubation

• LMA / intubating LMA

• Glide scope

• fiberoptic intubation

• surgical airway

• needle

• percutaneous

• open

ATLS Specifics

• Alternative Airway Devices/Options

ATLS Specifics

• Surgical Airway

ATLS Specifics

• A - airway (with C-spine protection)

• ATLS:

• lateral C spine film
• complete C spine series during secondary survey

• Current practice:

• in ER assume C spine injury
• no C spine films in ER
• CT scan of C spine with reconstructions

ATLS Specifics

• A - airway (with C-spine protection)

• “Clearing” the C spine (multiple trauma patient)

• rarely done in ER (except fully conscious, no distracting injury)
• CT scan with reconstructions
• Further studies
• MRI
• Flexion - Extension views

ATLS Specifics

• B – breathing

• oxygenation

• ventilation

• monitoring

• clinical (auscultation)

• O2 saturation

• EtCO2

• ABG’s

ATLS Specifics

• C - circulation (shock management)

• recognition and resuscitation from shock

• post traumatic shock is hemorrhagic shock until proven otherwise

ATLS Specifics

• C - circulation (shock management)

• Classification and mechanisms of shock

• obstructive

• tension pneumothorax
• cardiac tamponade

• Tension pneumothorax is the most EASILY corrected cause of shock

ATLS Specifics

• C - circulation (shock management)

• Classification and mechanisms of shock

• distributive

• spinal cord injury
• sepsis
• anaphylaxis

ATLS Specifics

• C - circulation (shock management)

• Classification and mechanisms of shock

• cardiogenic

• myocardial contusion
• valvular disruption
• ischemic injury

ATLS Specifics

• C - circulation (shock management)

• Classification and mechanisms of shock

• hypovolemic

• blood loss
• fluid loss

ATLS Specifics

• C - circulation (shock management)

• ACS Classes of Hemorrhage

• classes I - IV

• based on estimated blood loss and effect on vital signs

ATLS Specifics

• C – circulation (shock management)

• STOP the BLEEDING

• External blood loss

• Internal blood loss

• REPLACE blood loss

ATLS Specifics

• C – circulation (shock management)

• Vascular access

• Direct pressure

• Fluid administration

• Assessment of response

ATLS Specifics

• C – circulation (shock management)

• Fluid Administration

• ATLS: initial 2 litre bolus of warmed Ringer’s (NS)

ATLS Specifics

• C – circulation (shock management)

• Crystalloid

• Isotonic

• Hypertonic

• Colloid

• Albumin

• Starch (Pentaspan, Voluven)

ATLS Specifics

• Fluid Administration - which fluid?

• Crystalloid
• massive fluid administration
• diffuse edema (?worsens cerebral edema)
• ?contributes to “compartment syndrome”
• Colloid
• no demonstrated benefit (?harm, SAFE trial)
• costlier
• Hypertonic saline (3%, 7.5% =/- dextran)
• no demonstrated benefit (trial in progress)
• hypernatremia

ATLS Specifics

• C – circulation (shock management)

• Blood replacement

• type O
• type specific
• fully crossmatched

ATLS Specifics

• C - circulation (shock management)

• Role of Factor VIIa

• initially used for hemophilia
• initiates thrombin formation by binding with exposed tissue factor
• reverses coagulopathy
• use after
• surgically accessible bleeding controlled
• coag factors and platelets

ATLS Specifics

• C - circulation (shock management)

• Role of Factor VIIa

• parallel RCT’s in blunt/pen trauma (JTrauma 05) decreased RBC use in blunt trauma better outcome in coagulopathic patients (CCM 06)
• better outcome in TBI (NEJM 05)
• multiple case reports/series showing benefit in reversal of coagulopathy and lower transfusion

ATLS Specifics

• C – circulation (shock management)

• Stop Internal Bleeding

• chest, abdomen, pelvis

ATLS Specifics

• Recognition of thoracic hemorrhage

• clinical
• CXR
• Chest tube(s)

ATLS Specifics

• Recognition of abdominal hemorrhage

• clinical
• FAST
• DPL
• laparotomy

ATLS Specifics

• Recognition of pelvic hemorrhage

• clinical
• pelvic x-ray
• CT scan

Damage Control Laparotomy

• Part 1

• stop all overt arterial bleeding
• pack other bleeding
• control contamination
• modified closure

Damage Control Laparotomy

• Part 2

• return to ICU for warming, correction of coagulation and acidosis

• Part 3

• return to OR for definitive closure

ATLS Specifics

• D – (neurologic) Disability

• ATLS: rapid recognition of lateralizing injury (potentially surgically correctable)
• confirmation by CT scan
• emergency craniotomy for drainage

ATLS Specifics

• E - exposure / environment

• remove clothing
• keep covered between examinations (hypothermia)
• logroll
• full examination of extremities

Thanks

• Q –questions?