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



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Trauma: The Golden Hour

  • Dennis Kim MD FRCS(C)

  • General Surgery

  • Trauma & Critical Care POS Core Lecture Series

  • February 17 2009




Objectives

  • concept of a golden hour

  • pathophysiology of shock in the trauma patient

  • resuscitation according to ATLS principles

    • overview
    • specifics


The Golden Hour

  • originated by R Adams Cowley

  • first sixty minutes after the occurrence of multi-system trauma

  • victim's chances of survival are greatest if they receive definitive care in the OR within the first hour after a severe injury



The Golden Hour

  • recently, the validity of the “golden hour” as a rigidly defined timeframe scrutinized

  • core principle of rapid intervention in trauma cases remains universally accepted



The Golden Hour

  • "There is a golden hour between life and death. If you are critically injured you have less than 60 minutes to survive. You might not die right then; it may be three days or two weeks later -- but something has happened in your body that is irreparable."

  • - R Adams Cowley





The Golden Hour

    • Time and Trauma Outcomes
    • no convincing studies that time to treatment consistently leads to better outcome
    • outcome related to many factors including reduced time between injury and definitive care
    • Ann Surg. 2003;237(2):153-60


1. What is the most common cause of shock in the trauma patient?

  •  septic

  • B) cardiogenic

  • C) hemorrhagic

  • D) neurogenic



2. The most easily reversible cause of shock in the trauma patient is:

  • A) hemorrhagic

  • B) neurogenic

  • C) tension pneumothorax

  • D) cardiac tamponade



3. The most commonly injured solid intraabdominal organ in blunt trauma is:

  • A) liver

  • B) spleen

  • C) kidney

  • D) small bowel



4. The bloody vicious cycle of trauma refers to:

  • A) bleeding, hypothermia, and acidosis

  • B) bleeding, hyperthermia, acidosis

  • C) transfusion, hypothermia, acidosis

  • D) transfusion, hypothermia, alkalosis



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?



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