The Hypotensive Trauma Patient

By Kane Guthrie

Trauma in WA

But what about SCGH?

The Guide

The Guidelines

The Hypotensive Trauma Patient

Causes?Haemorrhagic Causes Non-Haemorrhagic Causes

External bleeding Tension pneumothorax

Intra-thoracic bleeding Myocardial contusion

Intra-abdominal bleeding Pericardial tamponade

Pelvic fractures Spinal cord transection

Long bone fractures Coincident medical (AMI)

Case Study

The Approach

C :Catastrophic haemorrhageA: Airway > C-spineB: BreathingC: CirculationD: DisabilityE: Exposure

The Lethal Triad

Surveys

• Trauma Team Major Trauma CallED Trauma Call• Primary Survey• Secondary Survey

Physical Exam

Focus on:• ID all sites of external bleeding• ID external markers of torso injury• ID all penetrating wounds

Pearls• Roll the patient early• Don’t underestimate scalp bleeding

Diagnostic Testing

Bedside Testing:• AP CXR• AP Pelvis x-ray• FAST, EFASTDPL is out. Definitive Testing• CT scan (Donut of death)• Surgical Exploration (Laparotomy, Angio)

Ultrasound

• FAST &EFAST• Extension of physical exam• Patient doesn’t have to move to it• Looks for free fluid• Can also Dx PTX• Helpful for vascular access

Pathology

• Base deficit (VBG,ABG)• Haemoglobin• Lactate• HaematocritAll must be in a series.

Airway

Maintaining airway can be difficult R/T:• Maxillofacial trauma• Neck trauma• Laryngeal trauma• C-spine precautionsSecure airway early

C-Spine

• Maintain precautions until• Nexus Vs Canadian • Imaging• Clinically

Breathing

• Give O2 NRBM 15L• RSI with in-line stabilization• Prepare for difficult airway• Beware of pre-existing co-morbidities • Avoid hypotension, lower doses, ? use

Ketamine

Circulation

• Don’t rely on HR & BP• Place x 2 18g IVC• Consider IO early if difficult access• U/O and serial lactate guide Mx:• Ketamine ?better for intubation/analgesia• Fluid resuscitation blood is better• Crystalloid Vs Colloid• Do Inotropes have a role???

Massive Transfusion

• Focuses more on blood products than fluidsPredicting who needs M/TPenetrating mechanismSBP <90mmHgHR >120bpmPositive FAST abdominal views1:1:1 Ratios (PRBCS, FFP, Platlets)

Trendelenburg Position

• Time honored tradition • Limited evidence (more harm than good)• Effects are short livedComplications ^ dyspnea, hypoventilation and atelectasis Abdo organs into chest cavity decreasing venous

return to heart Risk of aspirating gastric contents?Leg elevation better than nothing

Disability

• TBI• ETOH, illicit, Metabolic (BSL),• GCS < 8 Intubate??? Prefer GCS <12• Maintain adequate perfusion

Exposure

• Get complete exposure during assessThen:• Keep patient warm• Give warm fluids• Monitor core temp= avoids hypothermia/ lethal triad.

Special Considerations

• Elderly• Athletes• Pregnancy• Medication • Hypothermia• Pacemaker

Interventions

• External Apply direct pressure, Suture Lacerations• Long Bone # Splint +/- reduce #• Chest ICC, Pigtail• Abdomen Emergency Laparotomy• Retroperitoneum Externally stabilse pelvis, Emergency Angiogram

Resources

• www.lifeinthefastlane.com• http://emcrit.org/• http://www.itim.nsw.gov.au/• www.trauma.org/