Post on 24-Jun-2020
The latest changes in evidence in
clinical management of trauma
Emergency Care Clinical Network
Associate Professor Rodney Judson
Director of Trauma
The Royal Melbourne Hospital
Outline
• State Trauma System
• Trauma resuscitation
• Early trauma care
▫ Triage
▫ Transfer
• Surgical Decision making
Victorian State Trauma System
• Implemented in 1999
▫ MTS now caring for 80% of major trauma patients
▫ Decreased inpatient hospital mortality from 15% to 11%
Success of Trauma System
State Trauma System
• Evolution of the system included
▫ Development of guidelines
▫ Refinements of the system
Via state trauma registry data/ meetings and reports
State Trauma System
• Development of guidelines
▫ Major trauma triage guidelines
Review resulted in:
prehospital trauma triage time to MTS changing from 30 to 45 mins
Change in vital signs to ensure 80% capture of MTS patients at scene
State Trauma System
• Validated prehospital triage of based on
▫ Vitals signs
▫ Injuries
▫ High Risk Mechanism
• Transfer to MTS time
▫ 45 mins
State Trauma System
Inter-Hospital Trauma Transfer
Vitals now the same as prehospital due to validation study
State Trauma System
• Adult Retrieval Victoria (ARV) ▫ Adult Retrieval Victoria is a single contact point for: Major Trauma
Critical Care Advice
Critical Care Bed Access
Retrieval of Critical Care Adult Patients State-wide.
▫ This state-wide service is available 24 hours, 365 days
a year.
Trauma Resuscitation
• To intubate or to not intubate
▫ Prehospital RSI randomised controlled trial Outcome: Severe TBI pts with prehosp RSI had
favourable outcomes at 6 months
▫ Bernard et al 2008
Trauma Resuscitation
• Permissive hypotension
▫ Hypotensive resuscitation and /or low volume resuscitation
Remain controversial in Australia
Part of damage control resuscitation along with
damage control surgery and haemostatic resuscitation
Targets SBP ≥ 70 & ≥ 90 with head injury
Trauma Resuscitation
• Permissive hypotension ▫ Problems Not widely accepted in Australia Studies based on animals mostly Varying interpretations Must not miss non haemorrhagic causes (ie PTX
etc) Prolonged retrieval times in Australia > 6hrs Concerns if ? Severe TBI Appropriate BP varies patient to patient
• No High level evidence to support this
Trauma Resuscitation
• Research says haemorrhage leading case of death
▫ Accounts for up to 80% of deaths in operating room
▫ Exsanguination noted internationally as the “leading cause of early hospital death”
RMH data 2013-2014 financial year
haemorrhage as principle cause of death in 1.42 %
Trauma Resuscitation
• Trauma Induced Coagulopathy (TIC)
▫ Systemic anticoagulation
▫ Fibrinolysis
Exacerbated by hypothermia, acidosis and haemodilution
• Coagulopathy present in up to ¼ of trauma patient
• Fluid resuscitation causes cellular changes
• Damage control resuscitation
▫ Improves haemostasis
▫ Haemorrhage control
▫ Limit haemodilution
▫ Hypothermia
▫ Improve outcomes
Trauma Resuscitation
• Change in Blood component therapy
▫ Early transfusion of Blood and blood components= early haemorrhage control
• Transfusion strategies
▫ Transfusion ratio 1:1:1
{ 4 units of RBC’s, 4 units (2 bags or 600mls) of FFP & 4 units (1 pooled/ aphorised bag) of platelets}
The Guideline Trauma Call
Primary Survey
A: Patent airway & C/spine protection
B: Ensure adequate breathing, circulation & oxygenation
C: Venous access 2 large bore cannualae; inspect for sources of bleeding
(take baseline bloods (Xmatch, FBC, Coags, Biochem)
D: Conduct GCS
E: Commence hyopthermia protocol: warm fluids & bare hugger
External Long Bones
CXR & PXR < 10 mins
DPA +/-FAST < 30mins
Interventions
Apply pressure
Splint long bones
Chest tubes
Trauma Laparotomy
Pelvic sling
Angiography
Massive Transfusion Trigger?
ABC Tool > or = 2
> 4units ~4 Hours
Continue with
Primary and
secondary
survey
Bolus 1 to 2 litres
warm crystalloid solution
Commence RBC's O Negative
(ensure bloods have been sent)
Initiate MEP 1
Blood Bank Telephone
27275 or 27276
Unknown patient protocol activated if relevant
Commence documentation on the Massive Transfusion Sheet
MEP 1 contents
4 units O Rh (D) Negative Red Cells
2 units FFP = 1 bag
4 units of Platelets = 1 pool
Massive Transfusion Fluid Balance Sheet
If theatre
required
urgently
initiate
Trauma
OPSTAT
Transfusion Triggers
Platelets < 75 x 10 9/L= 1 bag of plts
Platelets < 50 x 10 9/L = 2 bags of plts
INR > 1.5 = 2 bags FFP
INR > 2.0 = 4 bags FFP
Fibrinogen < 1.5g/L = 6 bags of cryo
Fibrinogen < 1.0g/L = 12 bags of cryo
Fibrinogen < 0.5g/L = 18 bags of cryo
Consider NovoSeven
Inconsultation with heamatology registrar
Inclusion
persistent uncontrolled heamorrhage
not managed by stabilistiaon, surgical
exploraiton or transfusion
Exclusion criteria
Ph < 7.15
Temp < 34 degrees
MEP PACK TWO
Blood Bank Telephone 27275 or 27276
And notify of patient location & clinical status
MEP 2 onwards contents
4 units O Rh (D) Negative Red Cells
4 units FFP = 2 bags
4 units Platelets = 1 pool
Massive Transfusion Fluid Balance Sheet
MEP PACK THREE
Contents same as MEP 2
Resuscitation Endpoints
Haemostatic Control
INR 1.5 or less
Fibrinogen 1.5 or more
Platelets > 50 or > 100 if critical structures
at risk of bleeding
PH > 7.20
SBP: 80-90 mmHg
Temperature > 36 degrees
On release of MEP 1
Blood bank notifies
Heamatology registrar who
will Telephone the Trauma
Team Leader in ED
on ext 24890
with the first coagulation
sample results
Release group
specific
products
ABC Tool
Penetrating Mechanism
ED SBP < 90mmHg
ED HR > 120 bpm
Positive Fast
No
Remember it can take
> 30mins to thaw FFP & Cryo
Yes
Minimise Crystalloid
Continue resusitation based on clinical parameters and ongoing bleeding
(ensure post administration bloods have been taken and sent)
Continue resusitation based on clinical parameters and ongoing bleeding
(ensure post administration bloods have been taken and sent)
Continue resusitation based on clinical parameters and ongoing bleeding
(ensure post administration bloods have been taken and sent)
Initiate MEP 1
Blood Bank Telephone
27275 or 27276
Unknown patient protocol activated if relevant
Commence documentation on the Massive Transfusion Sheet
MEP 1 contents
4 units O Rh (D) Negative Red Cells
2 units FFP = 1 bag
4 units of Platelets = 1 pool
Massive Transfusion Fluid Balance Sheet
Trauma Resuscitation
• Tranexamic Acid
▫ Crash 1 and 2 trials
Outcome
Early administration of TXA safely reduces risk of death in bleeding patients and is highly cost effective
$30 dose
~ 3 hrs of injury admin
▫ Outcomes
All cause mortality
16 % to 14.5%
Risk of death from bleeding was 5.7% to 4.9%
▫ RMH 1.42%
Trauma Resuscitation
• Many took this as definitive evidence have added TXA into protocols
▫ CRASH 2 Concerns
< 2% of cases treated in countries with modern trauma care standards
Access to blood and blood products, angiography and critical care
Baseline mortality was 16% even though only half received blood
VTE concerns rates increased 9-12 time in those who received TXA
Trauma Resuscitation
▫ Pre-Hospital Anti-fibrinolytics for Trauma Coagulopathy and Haemorrhage study (PATCH)
NHMRC funded Australia and New Zealand
Test the effect on mortality and recovery at 6 months
Include: coag, fibrinolysis, transfusion, VTE, immunity and sepsis
Trauma Resuscitation
• Proposed practice changes to inadequate perfusion guideline
▫ Arterial tourniquets
Bleeding limbs that cannot be managed simple pressure
▫ Vasopressors
In Traumatic brain injury unresponsive to resuscitation to maintain CPP
Target SBP 120mmHg
Early Trauma Care
• Spine immobilisation methods
▫ No randomised controlled trials
▫ Effect of immobilisation on trauma patients remains uncertain
Early Trauma Care • Spine immobilisation prehospital
▫ There is insufficient evidence to support treatment guidelines in prehospital N/Surg 2002
• Prehospital immobilisation criteria
▫ (AV 2012 clinical practice guidelines) Age >55 History of bone disease Decreased GCS Drug of ETOH Significant Distracting injury Spinal column pain/ tenderness Neuro deficit
• Not for use in paediatrics
•
Early Trauma Care
• Cervical Spine Clearance ▫ Cervical Spine injury incidence in blunt 14% 92% are fractures & 14% ligamentous injuries
▫ RMH Trauma Registry Report 2013-2014
▫ CT scan is “gold standard” for assessment with
100% detection of bony injuries (Vanguri et al 2014)
▫ However limited in soft tissue assessment MRI more sensitive but timing is important Sensitivity decreases ~ 72hrs
Early Trauma Care
• RMH cervical spine clearance 2014 Study
▫ demonstrated average of 11.3 hrs to spine clearance, Median and Mode 5hrs
▫ No incidence of pressure sores related to cervical collars
• RMH over all since 1999 we have had a 90% decease in time to clearance and 100% decrease in collar related pressure injuries
RMH time to spinal clearance
64 61
95
25
193
100
119
86.49
95.84
49.12
25.5
11.3
0
20
40
60
80
100
120
140
160
180
200
1999 2000 2001 2002 2005 2013
Patients
Average Hours
Early Trauma Care
Symptomatic treatment in cervical collar with referral to Orthopaedic unit
+/- MRI (MRI most sensitive < 72 hrs to
ligamentous injury)
Patient clinically assessed
as having full range of motion of their cervical
spine with no pain and assess as to high risk
criteria?
CT NAD
No
Yes
Yes
No
Cervical Spine Helical CT Occiput to T1
Yes to any
NEXUS criteria
Is there any: Reduction in conscious state / alertness?Intoxication?Posterior midline tenderness?Focal neurological deficit?
Painful distracting injury?
Potential Cervical Spine InjuryMaintain Spinal Precautions
No to all
Spine "cleared"
Collar off
Document on spinal management
chart/ symphony and
or medical record
High Risk of Ligamentous Injury
elderly > 65
Advanced degenerative disease
TL fracture
Multidirectiona forces
ejection
Axial Load
Fall > 3 metres or 5 stairs
Quad bikes/ Bikes
Early Trauma Care • Standard needle decompression
▫ Normal IV catheters don’t reach in 65% of cases
Can J Surg. 2010 Jun;53(3):184-8.
Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7
J Trauma. 2008 Jan;64(1):111-4
J Trauma 2008 Oct;65(4)”:964
Accid Emerg Med 1996;6:426–7
Injury 1996;5:321–2.
• Finger Thoracostomy ▫ Indications
Any pneumothorax in a patient undergoing positive pressure ventilation
Actual or near traumatic cardiac arrest
Shocked state with no apparent cause
Early Trauma Care • Finger Thoracostomy
▫ Advantages The lung can be felt / seen to re-expand
If the patient persists in a shocked state during transport, the thoracostomy can be “re-fingered” to ensure the lung is up, thus excluding one cause of obstructive shock
Avoids intubation of the chest in a non-clinical area
Avoids risk of re-tension caused by blockage and kinking of drainage systems
▫ Disadvantages Invasive
Risk of thoracostomies becoming occluded by patient’s arms when packaged
▫ Fitzgerald M, Mackenzie CF, Marasco S, Hoyle R, Kossmann T. Pleural decompression and drainage during trauma reception and resuscitation. Injury. 2008 Jan;39(1):9-20. doi: 10.1016/j.injury.2007.07.021. Review. PubMed PMID: 18164300
Early Trauma Care
• CT scanning Pan Scan Vs Selective Imaging
▫ Lower mortality in “pan scan” Vs selective
▫ Shorter emergency times
▫ Pan scan
Higher MOF and mechanical ventilation days
LOS not different
Early Trauma Care • CT scanning Pan Scan Vs Selective Imaging
▫ Initial Imaging strategies of Trauma Patients at Victoria's Two Major Adult
Trauma Centres Surenda, AMS 2014
▫ Results
hospital A more selective CT scanning ▫ 3x more likely to require additional imaging
▫ Ending up same total scans as hospital B at 24hrs ▫ Concerns re radiation dosages and trips to radiology and cost
hospital B more whole body ▫ more guideline approach to care , 2x odd of receiving WBCT ▫ 4x patients went home or to SSU in first 24hrs
Trauma Resuscitation
• CT scanning
▫ Blunt abdominal trauma
6% of all major injuries
Early in 20th century abdominal trauma high mortality and low threshold for laparotomy
CT scanning resulted
Change to non-operative management decisions
Availability of CT scanners and intro of embolisation
▫ Reduced mortality
Early Trauma
• Focused Assessment Sonograph Trauma (FAST)
▫ Change methods of diagnosing blunt abdominal trauma
Refine decision making & enable cx management
Also used for diagnosis of
Pericardial tamponade and pneumothorax
Surgical Intervention
ED Thoracotomy Guidelines
• Penetrating Trauma Indication
▫ < 5mins CPR on arrival
▫ Patient in extremis on arrival to ED
▫ Witnessed cardiac arrest in ED
• Blunt Trauma Indication
▫ Witnessed cardiac arrest in the ED
Penetrating Chest Trauma Extremis (BP <60 not responding to fluid resusitation)
and/ or CPR < 10 mins with signs of life
Signs of Life Pupil response
Respiratory effortCardiac activity
Spontaneous Movement Palpable pulse
Cessation of treatment
Downgrade Trauma OPSTAT
Notify theatre # 6312 or 6311
Call Cardiothoracics
and
Perform an EDT
Return of
SOL URGENT THEATRE
Aims of EDT Release tamponade
Control haemorrhageControl air embolism
Open cardiac massageCross clamp aorta
Patient arrives in extremis with blunt
or penetrating chest trauma Primary/ Secondary Survey
No
Blunt Torso Trauma Witness Cardiac Arrest
Signs of
life
Yes
No
No
Cessation of EDT Irreparable damage
Unsurvivable head injuriesPulseless electrical activity
Systolic <70 after 15-20 minsAsystolic arrest
Patient Requires Urgent
Thoracotomy
Call cardiothoracics
No
Emergency Department Thoracotomy
Yes
Yes
If patient is expected with penetrating/ blunt chest trauma in extremis notify cardiothoracic team
TRAUMA OPSTAT
Yes
No
Yes
Yes
Operative Guidelines Damage control
Laparotomy < 1 hr duration
Stop bleeding
Clamps/ packs
Stem contamination
Staple
Drain/ removal of septic focus
Laparostomy/ dressing
Trauma Resuscitation • Pregnancy
▫ Look after the mother look after the fetus
• Radiation
▫ The fear of cancer risk from CT scans should never influence he appropriate radiologic evolution of the trauma patient
▫ CT scanning has never been shown to cause cancer but has saved many lives with it proper and appropriate use
Thank you