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Anesthesia for multiple trauma:from the field to the OR

Anesthesia for multiple trauma:Anesthesia for multiple trauma:from the field to the ORfrom the field to the OR

Gary Hartstein, M.D.

Service d'Anesthésie-RéanimationService des Urgences

CHU Liège B.354000 Liège

Gary Hartstein, M.D.Gary Hartstein, M.D.

Service Service d'Anesthésied'Anesthésie--RéanimationRéanimationService Service des Urgencesdes Urgences

CHU Liège B.35CHU Liège B.354000 Liège4000 Liège

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Course outlineCourse outlineCourse outline

• philosophy of trauma care• ATLS principles• pre-hospital phase• emergency department phase• operating room phase

•• philosophy of trauma carephilosophy of trauma care•• ATLS principlesATLS principles•• pre-hospital phasepre-hospital phase•• emergency department phaseemergency department phase•• operating room phaseoperating room phase

GMHGMH

Course outlineCourse outlineCourse outline

• philosophy of trauma care• ATLS principles• pre-hospital phase• emergency department phase• operating room phase

•• philosophy of trauma carephilosophy of trauma care•• ATLS principlesATLS principles•• pre-hospital phasepre-hospital phase•• emergency department phaseemergency department phase•• operating room phaseoperating room phase

GMHGMH

Philosophy of trauma carePhilosophy of trauma carePhilosophy of trauma care

• trauma is a surgical disease• trauma requires a team approach at all phases– pre-hospital– emergency department– operating room– intensive care unit

•• trauma is a surgical diseasetrauma is a surgical disease•• trauma requires a team approach at all phasestrauma requires a team approach at all phases–– pre-hospitalpre-hospital–– emergency departmentemergency department–– operating roomoperating room–– intensive care unitintensive care unit

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Philosophy of trauma carePhilosophy of trauma carePhilosophy of trauma care

• trauma is a dynamic process– TEMPORAL EVOLUTION• primary lesion(s)• secondary lesion(s)

– "GEOGRAPHIC" EVOLUTION• site → emergency department → OR → ICU

– patient factors– response to therapeutic interventions

⇒ requires constant re-evaluation

•• trauma is a dynamic processtrauma is a dynamic process–– TEMPORAL EVOLUTIONTEMPORAL EVOLUTION•• primary lesion(s)primary lesion(s)•• secondary lesion(s)secondary lesion(s)

–– "GEOGRAPHIC" EVOLUTION"GEOGRAPHIC" EVOLUTION•• site site →→ emergency department emergency department →→ OR OR →→ ICU ICU

–– patient factorspatient factors–– response to therapeutic interventionsresponse to therapeutic interventions

⇒⇒ requires constant re-evaluation requires constant re-evaluation

AVOID AVOIDABLE DEATH AND DISABILITYAVOID AVOIDABLE DEATH AND DISABILITY

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Trimodal death distributionTrimodal Trimodal death distributiondeath distribution

Early deathsEarly deathsEarly deaths

0 2 4 1 3 5 (hours) (weeks) 0 2 4 1 3 50 2 4 1 3 5 (hours) (weeks) (hours) (weeks)

Num

ber o

f dea

ths

Num

ber o

f dea

ths

Num

ber o

f dea

ths

Immediate deathsImmediate deathsImmediate deaths

Late deathsLate deathsLate deaths

GMHGMH

Course outlineCourse outlineCourse outline

• philosophy of trauma care• ATLS principles• pre-hospital phase• emergency department phase• operating room phase

•• philosophy of trauma carephilosophy of trauma care•• ATLS principlesATLS principles•• pre-hospital phasepre-hospital phase•• emergency department phaseemergency department phase•• operating room phaseoperating room phase

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ATLS principlesATLS principlesATLS principles

• Advanced Trauma Life Support®

• trauma kills in reproducible time-frames• "ABCDE" approach– priorities established according to risk– emphasize first hour after injury– SYSTEMATIC approach to trauma victim

•• AAdvanced dvanced TTrauma rauma LLife ife SSupportupport®®

•• trauma kills in reproducible time-framestrauma kills in reproducible time-frames•• "ABCDE" approach"ABCDE" approach–– priorities established according to riskpriorities established according to risk–– emphasize first hour after injuryemphasize first hour after injury–– SYSTEMATIC SYSTEMATIC approach to trauma victimapproach to trauma victim

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• primary survey

• resuscitation

• secondary survey

• continuing monitoring and re-evaluation

• definitive care

•• primary surveyprimary survey

•• resuscitationresuscitation

•• secondary surveysecondary survey

•• continuing monitoring and re-evaluationcontinuing monitoring and re-evaluation

•• definitive caredefinitive care

ATLS sequence of careATLS sequence of careATLS sequence of care

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The "ABCs" of ATLSThe "ABCs" of ATLSThe "ABCs" of ATLS

• Airway (with cervical-spine control)

• Breathing

• Circulation (with control of hemorrhage)

• Disability

• Exposure (with temperature control)

•• AAirway (with cervical-spine control)irway (with cervical-spine control)

•• BBreathingreathing

•• CCirculation (with control of hemorrhage)irculation (with control of hemorrhage)

•• DDisabilityisability

•• EExposure (with temperature control)xposure (with temperature control)

GMHGMH

Course outlineCourse outlineCourse outline

• philosophy of trauma care• ATLS principles• pre-hospital phase• emergency department phase• operating room phase

•• philosophy of trauma carephilosophy of trauma care•• ATLS principlesATLS principles•• pre-hospital phasepre-hospital phase•• emergency department phaseemergency department phase•• operating room phaseoperating room phase

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Goals of pre-hospital careGoals of pre-hospital careGoals of pre-hospital care

• AVOID SECONDARY VICTIMS• minimize secondary lesions– secure airway, provide O2, ensure ventilation

• packaging• provide necessary analgesia• prepare receiving hospital

•• AVOID SECONDARY VICTIMSAVOID SECONDARY VICTIMS•• minimize secondary lesionsminimize secondary lesions–– secure airway, provide Osecure airway, provide O22, ensure ventilation, ensure ventilation

•• packagingpackaging•• provide necessary analgesiaprovide necessary analgesia•• prepare receiving hospitalprepare receiving hospital

provide MEDICAL careprovide MEDICAL careprovide MEDICAL care

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Limitations of pre-hospital careLimitations of pre-hospital careLimitations of pre-hospital care

• "scoop and run" vs. "stay and play"• physiologic normality is NOT goal• example: penetrating thoraco-abdominal trauma– increased mortality with fluid therapy– increased ICU complications– concept of "permissive hypotension"

•• "scoop and run" "scoop and run" vs. vs. "stay and play""stay and play"•• physiologic normality is NOT goalphysiologic normality is NOT goal•• example: penetrating thoraco-abdominal traumaexample: penetrating thoraco-abdominal trauma–– increased mortality with fluid therapyincreased mortality with fluid therapy–– increased ICU complicationsincreased ICU complications–– concept of "concept of "permissive hypotensionpermissive hypotension""

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Practical aspectsPractical aspectsPractical aspects

• spinal stabilization– rigid cervical collar, KED®, vacuum mattress,

spine board• analgesia / sedation– potent opioids, titrated to effect– low-dose ketamine– midazolam for amnesia, anxiolysis

• anesthesia– indications, choice of agents– preparation (!!!)

•• spinal stabilizationspinal stabilization–– rigid cervical collar, KEDrigid cervical collar, KED®®, vacuum mattress,, vacuum mattress,

spine boardspine board•• analgesia / sedationanalgesia / sedation–– potent opioids, titrated to effectpotent opioids, titrated to effect–– low-dose ketaminelow-dose ketamine–– midazolam for amnesia, anxiolysismidazolam for amnesia, anxiolysis

•• anesthesiaanesthesia–– indications, choice of agentsindications, choice of agents–– preparation (!!!)preparation (!!!)

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Prepare / choose receiving hospitalPrepare / choose receiving hospitalPrepare / choose receiving hospital

• closest appropriate facility (burns, cardio-thoracic trauma, neurosurgery, etc)

• transmit necessary information:– time of injury– related events– patient history– mechanism of injury– initial status and response to treatment– estimated time of arrival

•• closest closest appropriateappropriate facility (burns, facility (burns, cardiocardio--thoracic trauma, neurosurgery, etc)thoracic trauma, neurosurgery, etc)

•• transmit necessary information:transmit necessary information:–– time of injurytime of injury–– related eventsrelated events–– patient historypatient history–– mechanism of injurymechanism of injury–– initial status and response to treatmentinitial status and response to treatment–– estimated time of arrivalestimated time of arrival

GMHGMH

Course outlineCourse outlineCourse outline

• philosophy of trauma care• ATLS principles• pre-hospital phase• emergency department phase• operating room phase

•• philosophy of trauma carephilosophy of trauma care•• ATLS principlesATLS principles•• pre-hospital phasepre-hospital phase•• emergency department phaseemergency department phase•• operating room phaseoperating room phase

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Primary surveyPrimary surveyPrimary survey

• AIRWAY (with C-spine control)– identify obstruction (inspect, palpate)– maneuvers: jaw thrust > chin lift, suction– devices: oral airway, nasopharyngeal airway– definitive airway control

• cervical-spine protection– neutral position, alignment of head-neck-trunk– immobilization

•• AAIRWAY (with C-spine control)IRWAY (with C-spine control)–– identify obstruction (inspect, palpate)identify obstruction (inspect, palpate)–– maneuvers: jaw thrust > chin lift, suctionmaneuvers: jaw thrust > chin lift, suction–– devices: oral airway, nasopharyngeal airwaydevices: oral airway, nasopharyngeal airway–– definitive airway controldefinitive airway control

•• cervical-spine protectioncervical-spine protection–– neutral position, alignment of head-neck-trunkneutral position, alignment of head-neck-trunk–– immobilizationimmobilization

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Resuscitation: airway controlResuscitation: airway controlResuscitation: airway control

• definitive control: endotracheal intubation• indications for intubation– obstruction unresponsive to maneuvers– SpO2 < 90% on supplemental oxygen– shock (e.g. Bpsyst < 90 mm Hg)– head injury / unconsciousness (GCS ≤ 8)– anticipated surgery with multiple injuries– agitation rendering care difficult

•• definitive control: definitive control: endotracheal intubationendotracheal intubation•• indications for intubationindications for intubation–– obstruction unresponsive to maneuversobstruction unresponsive to maneuvers–– SSppOO22 < 90% on supplemental oxygen < 90% on supplemental oxygen–– shock (e.g. Bpshock (e.g. Bpsystsyst < 90 mm Hg) < 90 mm Hg)–– head injury / unconsciousness (GCS head injury / unconsciousness (GCS ≤≤ 8) 8)–– anticipated surgery with multiple injuriesanticipated surgery with multiple injuries–– agitation rendering care difficultagitation rendering care difficult

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Intubation technique: trauma patientsIntubation technique: trauma patientsIntubation technique: trauma patients

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C-spine protectionC-spine protectionC-spine protection

• MANUAL immobilization when collar off• ASSUME c-spine injury with trauma– depressed level of consciousness– blunt injury (esp. above clavicle)

• spine not cleared until:– full, adequate neurologic exam– AND full, adequate radiology studies (5 views !!!)

•• MANUALMANUAL immobilization when collar off immobilization when collar off•• ASSUME ASSUME c-spine injury with traumac-spine injury with trauma–– depressed level of consciousnessdepressed level of consciousness–– blunt injury (esp. above clavicle)blunt injury (esp. above clavicle)

•• spine not cleared until:spine not cleared until:–– full, adequate neurologic examfull, adequate neurologic exam–– ANDAND full, adequate radiology studies (5 views !!!)full, adequate radiology studies (5 views !!!)

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Primary surveyPrimary surveyPrimary survey

• BREATHING– inspection, palpation, percussion, auscultation• tension pneumothorax

• flail chest (pulmonary contusion)

• open pneumothorax

• massive hemothorax

•• BBREATHINGREATHING–– inspection, palpation, percussion, auscultationinspection, palpation, percussion, auscultation•• tension pneumothoraxtension pneumothorax

•• flail chest (pulmonary contusion)flail chest (pulmonary contusion)

•• open pneumothoraxopen pneumothorax

•• massive massive hemothoraxhemothorax

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Resuscitation: breathingResuscitation: breathingResuscitation: breathing

• 100% O2 to ALLpatients

• non-rebreathing maskwith reservoir

• 12-15 l/m flow

•• 100% O 100% O22 to to ALLALLpatientspatients

•• non-rebreathing mask non-rebreathing maskwith reservoirwith reservoir

•• 12-15 l/m flow 12-15 l/m flow

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• CIRCULATION (with hemorrhage control)– predominant cause of treatable deaths– hypotension = hypovolemia until proven otherwise– rapid assessment of hemodynamic status• LEVEL OF CONSCIOUSNESS• PULSE (central and peripheral, bilaterally)• skin color, capillary refill, temperature

– identify and control external hemorrhage

•• CCIRCULATION (with hemorrhage control)IRCULATION (with hemorrhage control)–– predominant cause of treatable deathspredominant cause of treatable deaths–– hypotension = hypovolemia until proven otherwisehypotension = hypovolemia until proven otherwise–– rapid assessment of hemodynamic statusrapid assessment of hemodynamic status•• LEVEL OF CONSCIOUSNESSLEVEL OF CONSCIOUSNESS•• PULSE (central and peripheral, bilaterally)PULSE (central and peripheral, bilaterally)•• skin color, capillary refill, temperatureskin color, capillary refill, temperature

–– identify and control external hemorrhageidentify and control external hemorrhage

Primary surveyPrimary surveyPrimary survey

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Grades of shockGrades of shockGrades of shock

Class Blood lossml (%)

Pulse > 100 ↓ Syst-diast ↓ BP

I ≤ 750 (≤ 15%)

II 750 Ğ 1500(15 Ğ 30%)

+ +

III 1500 Ğ 2000(30 Ğ 40%)

++ + ++

IV > 2000(> 40%)

+++ +++ +++

Class Blood lossml (%)

Pulse > 100 ↓ Syst-diast ↓ BP

I ≤ 750 (≤ 15%)

II 750 Ğ 1500(15 Ğ 30%)

+ +

III 1500 Ğ 2000(30 Ğ 40%)

++ + ++

IV > 2000(> 40%)

+++ +++ +++

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Resuscitation: circulationResuscitation: circulationResuscitation: circulation

• ≥ 2 large bore peripheral venous catheters– at least 16 gauge

• consider bi-caval placement• remember external jugular, femoral veins• adult: cutdowns• children: interosseous• draw labs: heme, coag, T&X, tox, β-HCG

•• ≥≥ 2 large bore peripheral venous catheters 2 large bore peripheral venous catheters–– at least 16 gaugeat least 16 gauge

•• consider bi-caval placementconsider bi-caval placement•• remember external jugular, femoral veinsremember external jugular, femoral veins•• adult: cutdownsadult: cutdowns•• children: interosseouschildren: interosseous•• draw labs: heme, coag, T&X, tox, draw labs: heme, coag, T&X, tox, β β-HCG-HCG

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Resuscitation: fluid therapyResuscitation: fluid therapyResuscitation: fluid therapy

• hypotensive: BLUNT trauma– adult: up to 2 liters warmed lactated Ringer's– child: up to 2 x 20 ml/kg warmed lactated Ringer's– inadequate response: transfuse; consider O.R.,

other diagnoses• hypotensive: PENETRATING THORACO-

ABDOMINAL– airway, 100% O2– venous access– tolerate Bpsyst ≥ 70 mm Hg

•• hypotensive: hypotensive: BLUNT BLUNT traumatrauma–– adult: up to 2 liters adult: up to 2 liters warmedwarmed lactated Ringer's lactated Ringer's–– child: up to 2 x 20 ml/kg child: up to 2 x 20 ml/kg warmedwarmed lactated Ringer's lactated Ringer's–– inadequate response: transfuse; consider O.R.,inadequate response: transfuse; consider O.R.,

other diagnosesother diagnoses•• hypotensive: hypotensive: PENETRATINGPENETRATING THORACO-THORACO-

ABDOMINALABDOMINAL–– airway, 100% Oairway, 100% O22

–– venous accessvenous access–– tolerate Bptolerate Bpsystsyst ≥≥ 70 mm Hg 70 mm Hg

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• DISABILITY (neurological evaluation)– pupils: symmetry, reactions– GCS (Glasgow Coma Score)• eye opening• verbal response• motor response

•• DDISABILITY (neurological evaluation)ISABILITY (neurological evaluation)–– pupils: symmetry, reactionspupils: symmetry, reactions–– GCS (Glasgow Coma Score)GCS (Glasgow Coma Score)•• eye openingeye opening•• verbal responseverbal response•• motor responsemotor response

Primary surveyPrimary surveyPrimary survey

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• EXPOSURE (with environmental control)– fully undress victim

–MAINTAIN CORE TEMPERATURE• warm blankets

• warmed fluids

• warm environment

•• EEXPOSURE (with environmental control)XPOSURE (with environmental control)–– fully undress victimfully undress victim

––MAINTAIN CORE TEMPERATUREMAINTAIN CORE TEMPERATURE•• warm blanketswarm blankets

•• warmed fluidswarmed fluids

•• warm environmentwarm environment

Primary surveyPrimary surveyPrimary survey

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Intra-hospital transfers / transportIntra-hospital transfers / transportIntra-hospital transfers / transport

• pre-arrival preparation• sufficient help– anesthesia personnel– nursing personnel

• sufficient supplies– (warmed) fluids– drugs– oxygen

• sufficient communication• proper monitoring• MAINTAIN NORMOTHERMIA

•• pre-arrival preparationpre-arrival preparation•• sufficient helpsufficient help–– anesthesia personnelanesthesia personnel–– nursing personnelnursing personnel

•• sufficient suppliessufficient supplies–– (warmed) fluids(warmed) fluids–– drugsdrugs–– oxygenoxygen

•• sufficient communicationsufficient communication•• proper monitoringproper monitoring•• MAINTAIN NORMOTHERMIAMAINTAIN NORMOTHERMIA

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Radiology: unstable patientRadiology: unstable patientRadiology: unstable patient

• 3 standard X-rays– lateral cervical spine (include C7-T1 interspace)– AP chest– AP pelvis

• abdominal / cardiac / thoracic ultrasound• immediate surgery?

•• 3 standard X-rays3 standard X-rays–– lateral cervical spine (include C7-T1 lateral cervical spine (include C7-T1 interspaceinterspace))–– AP chestAP chest–– AP pelvisAP pelvis

•• abdominal / cardiac / thoracic ultrasoundabdominal / cardiac / thoracic ultrasound•• immediate surgery?immediate surgery?

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Radiology: stabilized patientRadiology: stabilized patientRadiology: stabilized patient

• stabilized by SMUR or in ER• intubated / sedated• 3 standard X-rays• "body - scan" (+ spiral scan cervical spine)• full radiological imaging (spine in toto + sites of

suspected bony injury)

•• stabilized by SMUR or in ERstabilized by SMUR or in ER•• intubated intubated / sedated/ sedated•• 3 standard X-rays3 standard X-rays•• "body - scan" (+ spiral scan cervical spine)"body - scan" (+ spiral scan cervical spine)•• full radiological imaging (spine full radiological imaging (spine in toto + in toto + sites ofsites of

suspected bony injury)suspected bony injury)

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Radiology: stable patientRadiology: stable patientRadiology: stable patient

• full standard imaging (include spine in toto)• body scan (even without obvious lesions)– pedestrian vs. car– fall > 6 meters– frontal collision– ejected from car OR car vs. motorcycle– death OR serious injury in same vehicle

•• full standard imaging (include spine full standard imaging (include spine in totoin toto))•• body scan (even without obvious lesions)body scan (even without obvious lesions)–– pedestrian vs. carpedestrian vs. car–– fall > 6 metersfall > 6 meters–– frontal collisionfrontal collision–– ejected from car OR car vs. motorcycleejected from car OR car vs. motorcycle–– death OR serious injury in same vehicledeath OR serious injury in same vehicle

GMHGMH

Course outlineCourse outlineCourse outline

• philosophy of trauma care• ATLS principles• pre-hospital phase• emergency department phase• operating room phase

•• philosophy of trauma carephilosophy of trauma care•• ATLS principlesATLS principles•• pre-hospital phasepre-hospital phase•• emergency department phaseemergency department phase•• operating room phaseoperating room phase

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Rapid "pre-anesthetic assessment"Rapid "pre-anesthetic assessment"Rapid "pre-anesthetic assessment"

• A llergies• M edications• P ast illnesses• L ast meal• E vents related to the injury

•• AA llergiesllergies•• MM edicationsedications•• P P ast ast illnessesillnesses•• LL ast ast mealmeal•• E E vents related to the injuryvents related to the injury

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Operating room: practical aspectsOperating room: practical aspectsOperating room: practical aspects

• re-verify ABCs, organize lines, take report• ALWAYS full stomach• often difficult intubations– maxillo-facial trauma– secretions / blood / vomitus

• conflicting priorities common– intracranial hypertension + systemic hypotension– agitated patient with difficult airway

•• re-verify ABCs, organize lines, take reportre-verify ABCs, organize lines, take report•• ALWAYS full stomachALWAYS full stomach•• often difficult intubationsoften difficult intubations–– maxillomaxillo-facial trauma-facial trauma–– secretions / blood /secretions / blood / vomitus vomitus

•• conflicting priorities commonconflicting priorities common–– intracranial hypertension + systemic hypotensionintracranial hypertension + systemic hypotension–– agitated patient with difficult airwayagitated patient with difficult airway

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• severe shock– 100% O2

– muscle relaxant– analgesic as tolerated (titrated doses opioid)– THEN amnesic as tolerated (e.g.. BZD, low dose

volatile agent)– THEN anesthesia as tolerated

•• severe shocksevere shock–– 100% O100% O22

–– muscle relaxantmuscle relaxant–– analgesic as tolerated (titrated dosesanalgesic as tolerated (titrated doses opioid opioid))–– THEN amnesic as tolerated (e.g.. BZD, low doseTHEN amnesic as tolerated (e.g.. BZD, low dose

volatile agent)volatile agent)–– THEN anesthesia as toleratedTHEN anesthesia as tolerated

Anesthetic technique: suggestionsAnesthetic technique: suggestionsAnesthetic technique: suggestions

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• mild - moderate hypotension– 100% O2

– etomidate OR ketamine– muscle relaxant– titrated opioid– low dose inhalation anesthetic (increase as

tolerated)– OR low dose propofol infusion (increase as

tolerated)

•• mild - moderate hypotensionmild - moderate hypotension–– 100% O100% O22

–– etomidate etomidate OROR ketamine ketamine–– muscle relaxantmuscle relaxant–– titratedtitrated opioid opioid–– low dose inhalation anesthetic (increase aslow dose inhalation anesthetic (increase as

tolerated)tolerated)–– OR low doseOR low dose propofol propofol infusion (increase as infusion (increase as

tolerated)tolerated)

Anesthetic technique: suggestionsAnesthetic technique: suggestionsAnesthetic technique: suggestions

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• isolated intracranial hypertension– 100% O2

– propofol (2-3 mg/kg) OR thiopental (3-5 mg/kg)– 0.1-0.25 µg/kg sufentanil or equivalent– 1.5 mg/kg lidocaine IV (90 sec before intubation)– avoid N2O– continuous propofol infusion– (low dose inhalational agent)

•• isolated intracranial hypertensionisolated intracranial hypertension–– 100% O100% O22

–– propofolpropofol (2-3 mg/kg) OR thiopental (3-5 mg/kg) (2-3 mg/kg) OR thiopental (3-5 mg/kg)–– 0.1-0.25 µg/kg sufentanil or equivalent0.1-0.25 µg/kg sufentanil or equivalent–– 1.5 mg/kg 1.5 mg/kg lidocaine lidocaine IV (90 sec beforeIV (90 sec before intubation intubation))–– avoid Navoid N22OO–– continuouscontinuous propofol propofol infusion infusion–– (low dose (low dose inhalational inhalational agent)agent)

Anesthetic technique: suggestionsAnesthetic technique: suggestionsAnesthetic technique: suggestions

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• major trauma cases– one anesthesia team leader– one anesthetist per infusion line– one "secretary"– keep infused fluid containers for post-op totals

• anticipate needs– transfusion requirements (esp. massive transfusion)– ICU bed

• AVOID HYPOTHERMIA

•• major trauma casesmajor trauma cases–– one anesthesia team leaderone anesthesia team leader–– one anesthetist per infusion lineone anesthetist per infusion line–– one "secretary"one "secretary"–– keep infused fluid containers for post-op totalskeep infused fluid containers for post-op totals

•• anticipate needsanticipate needs–– transfusion requirements (esp. massive transfusion)transfusion requirements (esp. massive transfusion)–– ICU bedICU bed

•• AVOID HYPOTHERMIAAVOID HYPOTHERMIA

Operating room: practical aspectsOperating room: practical aspectsOperating room: practical aspects

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Operating room: surgical prioritiesOperating room: surgical prioritiesOperating room: surgical priorities

• torso injuries with hypotension (± simultaneous)

• intracranial mass lesions

• peripheral vascular injuries

• orthopedic injuries

• maxillo-facial trauma

•• torso injuries with hypotension (± simultaneous)torso injuries with hypotension (± simultaneous)

•• intracranial mass lesionsintracranial mass lesions

•• peripheral vascular injuriesperipheral vascular injuries

•• orthopedic injuriesorthopedic injuries

•• maxillomaxillo-facial trauma-facial trauma

GMHGMH

QUESTIONS ?