Congresso Regionale SIMEU LiguriaMartedì 23 Ottobre 2018

GESTIONE DEL TRAUMA “INTERMEDIO”

IN PRONTO SOCCORSO

GESTIONE DEL TRAUMA “INTERMEDIO”

IN PRONTO SOCCORSO

Dott. Stefano SartiniUOC MECAU, Ospedale Policlinico S.Martino

LUISA, 68aaLUISA, 68aa

CHE “TIPO” DI TRAUMA

E’?

CHE “TIPO” DI TRAUMA

E’?

COME LO CLASSIFICO?

COME LO CLASSIFICO?

COSA FACCIO ORA?

COSA FACCIO ORA?

COME LO VALUTO?COME LO VALUTO?

PURE LA CONTORSIONISTA

STAMANI?!?!?

PURE LA CONTORSIONISTA

STAMANI?!?!?

Il trattamento del trauma grave

richiede…

Il trattamento del trauma grave

richiede…

…any life threatening

injury…

…any life threatening

injury…

DEFINIZIONEDEFINIZIONE

DEFINIZIONEDEFINIZIONE

Two injuries that are greater or equal to 3 on the AIS and one or more additional

diagnoses (pathologic condition), that is, hypotension (systolic blood pressure e 90

mm Hg,), unconsciousness (GCS score e 8), acidosis (base deficit e j6.0), coagulopathy (PTT Q 40 seconds or INR Q 1.4), and age

(Q70 years).

Two injuries that are greater or equal to 3 on the AIS and one or more additional

diagnoses (pathologic condition), that is, hypotension (systolic blood pressure e 90

mm Hg,), unconsciousness (GCS score e 8), acidosis (base deficit e j6.0), coagulopathy (PTT Q 40 seconds or INR Q 1.4), and age

(Q70 years).

20142014

Pape et al. J Trauma Acute Care Surg 2014; 77 (5): 780-786 Pape et al. J Trauma Acute Care Surg 2014; 77 (5): 780-786

TRAUMA INTERMEDIO o MINORE

TRAUMA INTERMEDIO o MINORE

POLITRAUMAPOLITRAUMA

TRAUMA INTERMEDIO o MINORE

TRAUMA INTERMEDIO o MINORE

POLITRAUMAPOLITRAUMADEFINIZIONEDEFINIZIONE

TRAUMA INTERMEDIO o MINORE

TRAUMA INTERMEDIO o MINORE

POLITRAUMAPOLITRAUMADEFINIZIONEDEFINIZIONE

DEA IDEA I DEA IIDEA II

TRAUMA SCORES…TRAUMA SCORES…PREOSPEDALIEROPREOSPEDALIERO

Revised Trauma ScoreTrauma center se <4

Revised Trauma ScoreTrauma center se <4

Mechanism-GCS-Age-Blood pressure

23-29 basso rischio18-22 rischio intermedio

<18 alto rischio

Mechanism-GCS-Age-Blood pressure

23-29 basso rischio18-22 rischio intermedio

<18 alto rischio

TRAUMA SCORES…TRAUMA SCORES…INTRAOSPEDALIEROINTRAOSPEDALIERO

TRISSCorrelazione RTS/ISS

TRISSCorrelazione RTS/ISS

TRAUMA SCORES…TRAUMA SCORES…

Galvagno et al. Prehospital Emergency Care, Aug 2018, DOI: 10.1080/10903127.2018.1489019

Galvagno et al. Prehospital Emergency Care, Aug 2018, DOI: 10.1080/10903127.2018.1489019

TRAUMA SCORES…TRAUMA SCORES…

Bouzat et al.Injury, Int. J. Care Injured 47 (2016) 14–18 Bouzat et al.Injury, Int. J. Care Injured 47 (2016) 14–18

DEA IDEA I DEA IIDEA II

TRAUMA CENTERTRAUMA CENTER

TRAUMA CENTERTRAUMA CENTER

TRAUMA CENTERTRAUMA CENTER

TRAUMA CENTERTRAUMA CENTER

TRAUMA CENTERTRAUMA CENTER

TRAUMA CENTERTRAUMA CENTER

Step 1Step 1

• PA:110/70• FC 90bpmR• GCS 15/15• Sat O2:

98%inaa

Step 2Step 2

• Caduta accidentale da sedia con trauma fianco sx, no trauma cranico.

Step 3Step 3

• ESAME OBIETTIVO

• Torace:MV ridotto base sx

• Cuore toni validi, ritmici

• Addome: trattabile dolorabile ipocondrio e fianco sx con ematoma, non ferite aperte

• EN nei limiti

Step 4Step 4

• ANAMNESI: Donna, 68 anni, assume Xarelto e Bisoprololo x FAC.Non allergie

Tornando a Luisa…Tornando a Luisa…

Devo fare ESAMI EMATICI? Quali?accesso venoso?

Devo fare ESAMI EMATICI? Quali?accesso venoso?

E se tutto è negativo…la

dimetto?

E se tutto è negativo…la

dimetto?

Indagini strumentali?

E-FAST? RX? O TC?

Indagini strumentali?

E-FAST? RX? O TC?

jOpreanu RC, Arrangoiz R, Stevens P, Morrison CA, Mosher BD, Kepros JP.

Hematocrit, systolic blood pressure and

heart rate are not accurate predictors for surgery to control

hemorrhage in injured patients. Am Surg. 2010;76:296–301.

jOpreanu RC, Arrangoiz R, Stevens P, Morrison CA, Mosher BD, Kepros JP.

Hematocrit, systolic blood pressure and

heart rate are not accurate predictors for surgery to control

hemorrhage in injured patients. Am Surg. 2010;76:296–301.

Acker SN, Petrun B, Partrick DA, Roosevelt

GE, Bensard DD. Lack of utility of repeat monitoring of hemoglobin and hematocrit following blunt solid organ injury in children. J Trauma Acute Care Surg. 2015;79:991–4 (discussion 994)

Acker SN, Petrun B, Partrick DA, Roosevelt

GE, Bensard DD. Lack of utility of repeat monitoring of hemoglobin and hematocrit following blunt solid organ injury in children. J Trauma Acute Care Surg. 2015;79:991–4 (discussion 994)

Madsen T, Dawson M, Bledsoe J, Bossart P.

Serial hematocrit testing does not identify major injuries in trauma

patients in an observation unit. Am J Emerg Med. 2010;28:472–6.

Madsen T, Dawson M, Bledsoe J, Bossart P.

Serial hematocrit testing does not identify major injuries in trauma

patients in an observation unit. Am J Emerg Med. 2010;28:472–6.

Thorson CM, Ryan ML, Van Haren RM, Pereira R, Olloqui J, Otero CA, et al. Change

in hematocrit during trauma assessment

predicts bleeding even with ongoing fluid resuscitation. Am Surg. 2013;79:398–

406.

Thorson CM, Ryan ML, Van Haren RM, Pereira R, Olloqui J, Otero CA, et al. Change

in hematocrit during trauma assessment

predicts bleeding even with ongoing fluid resuscitation. Am Surg. 2013;79:398–

406.

Bruns B, Lindsey M, Rowe K, Brown S, Minei JP, Gentilello LM, et al. Hemoglobin

drops within minutes of injuries and

predicts need for an intervention to stop hemorrhage. J Trauma. 2007;63:312–

5.

Bruns B, Lindsey M, Rowe K, Brown S, Minei JP, Gentilello LM, et al. Hemoglobin

drops within minutes of injuries and

predicts need for an intervention to stop hemorrhage. J Trauma. 2007;63:312–

5.

Paradis NA, Balter S, Davison CM, Simon G,

Rose M. Hematocrit as a predictor of significant injury after penetrating trauma. Am J Emerg Med. 1997;15:224–8.

Paradis NA, Balter S, Davison CM, Simon G,

Rose M. Hematocrit as a predictor of significant injury after penetrating trauma. Am J Emerg Med. 1997;15:224–8.

Knottenbelt JD. Low initial hemoglobin

levels in trauma patients: an important indicator of ongoing hemorrhage. J

Trauma. 1991;31:1396–9.

Knottenbelt JD. Low initial hemoglobin

levels in trauma patients: an important indicator of ongoing hemorrhage. J

Trauma. 1991;31:1396–9.

Figueiredo et al. Ann. Intensive Care (2018) 8:76 Figueiredo et al. Ann. Intensive Care (2018) 8:76

Baxter et al.J Trauma Acute Care Surg 2016: 81(3) 555-566 Baxter et al.J Trauma Acute Care Surg 2016: 81(3) 555-566

Severity of injury

Severity of injury

Multi organ failure

Multi organ failure

Respiratory complications

Respiratory complications

Blood transfusion

Blood transfusionSurgerySurgery

Mechanical ventilationMechanical ventilation

ICU admissionICU admission

CLEAR RELATIONSHIP LACTATE and MORTALITY

CLEAR RELATIONSHIP LACTATE and MORTALITY

Baxter et al.J Trauma Acute Care Surg 2016: 81(3) 555-566 Baxter et al.J Trauma Acute Care Surg 2016: 81(3) 555-566

E la E-FAST???E la E-FAST???

Montoya et al Eur J Trauma Emerg Surg (2016) 42:119–126 Montoya et al Eur J Trauma Emerg Surg (2016) 42:119–126

E la E-FAST???E la E-FAST???

Montoya et al Eur J Trauma Emerg Surg (2016) 42:119–126 Montoya et al Eur J Trauma Emerg Surg (2016) 42:119–126

E la E-FAST???E la E-FAST???

Montoya et al Eur J Trauma Emerg Surg (2016) 42:119–126 Montoya et al Eur J Trauma Emerg Surg (2016) 42:119–126

E la E-FAST???E la E-FAST???

Montoya et al Eur J Trauma Emerg Surg (2016) 42:119–126 Montoya et al Eur J Trauma Emerg Surg (2016) 42:119–126

E la E-FAST???E la E-FAST???

Montoya et al Eur J Trauma Emerg Surg (2016) 42:119–126 Montoya et al Eur J Trauma Emerg Surg (2016) 42:119–126

E la E-FAST???E la E-FAST???

Stengel et al. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD004446Stengel et al. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD004446

E la E-FAST???E la E-FAST???

Stengel et al. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD004446Stengel et al. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD004446

US/CT CORRELATIONSUS/CT CORRELATIONS

E la E-FAST???E la E-FAST???

Stengel et al. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD004446Stengel et al. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD004446

US vs Mortality and OutcomeUS vs Mortality and Outcome

The experimental evidence

justifying FAST-based clinical

pathways in diagnosing

patients with suspected

abdominal or multiple blunt

trauma remains poor.

PNXPNX

BTS Guideline 2010BTS Guideline 2010

>4cm>4cm

>2cm>2cm

FRATTURE COSTALIFRATTURE COSTALI

ALTO RISCHIOFrattura 1°-2°

costaalta energiaFrattura 9°-12°

danni organi addominali

ALTO RISCHIOFrattura 1°-2°

costaalta energiaFrattura 9°-12°

danni organi addominali

Rostas et al. The American Journal of Surgery (2017) 213, 791-797 Rostas et al. The American Journal of Surgery (2017) 213, 791-797

FRATTURE COSTALIFRATTURE COSTALI

FRATTURE COSTALIFRATTURE COSTALI

Chapman et al. J Trauma Acute Care Surg (2016); 80(1) : 95-101

Chapman et al. J Trauma Acute Care Surg (2016); 80(1) : 95-101

SCORE ≥ 490% Specificità x

POLMONITE/IRA/TRACHEOSTOMIA

SCORE ≥ 490% Specificità x

POLMONITE/IRA/TRACHEOSTOMIA

…sensibilità 23.1%...

…sensibilità 23.1%...

TRAUMA TORACICOTRAUMA TORACICO

Chen et al. Surgery 2014;156:988-94 Chen et al. Surgery 2014;156:988-94

SCORE ≥ 5Mortalità >10%SCORE ≥ 5Mortalità >10%

E la MILZA???E la MILZA???

Zarzaur et al. J Trauma Acute Care Surg. 2015;79: 335-342 Zarzaur et al. J Trauma Acute Care Surg. 2015;79: 335-342

RESULTS383 … enrolled. Of those

enrolled, 371 were discharged alive with a spleen.

ANGIO+EMBO 18,7%Overall Mortality: 1,04%

RESULTS383 … enrolled. Of those

enrolled, 371 were discharged alive with a spleen.

ANGIO+EMBO 18,7%Overall Mortality: 1,04%

CONCLUSIONSAfter the initial 24 hours, no additional interventions are warranted for patients with

Grade I injuries as long as there are no concerning features on admission CT such as a splenic

blush or a subcapsular hematoma.

CONCLUSIONSAfter the initial 24 hours, no additional interventions are warranted for patients with

Grade I injuries as long as there are no concerning features on admission CT such as a splenic

blush or a subcapsular hematoma.

TC TOTAL BODY???TC TOTAL BODY???

Sierink et al. BMC Emergency Medicine 2012, 12:4 Sierink et al. BMC Emergency Medicine 2012, 12:4

CRIT

ERI

INCL

USI

ON

ECR

ITER

I IN

CLU

SIO

NE

Compromissione emodinamica

Sospetto clinico di danno grave

Dinamica maggiore

TC TOTAL BODY

TC TOTAL BODY

Atteggiamento convenzionale

(ATLS)

Atteggiamento convenzionale

(ATLS)

END-POINTS:1. In-hospital

mortality2. Mortality 24h,

30days, adverse outcome

END-POINTS:1. In-hospital

mortality2. Mortality 24h,

30days, adverse outcome

TC TOTAL BODY???TC TOTAL BODY???

Sierink et al. Lancet 2016; 388: 673–83 Sierink et al. Lancet 2016; 388: 673–83

CONCLUSIONSWe found no difference in-

hospital mortality in patients with severe trauma who underwent immediate total-body CT scanning compared with the standard work up with conventional imaging and

selective CT scanning

CONCLUSIONSWe found no difference in-

hospital mortality in patients with severe trauma who underwent immediate total-body CT scanning compared with the standard work up with conventional imaging and

selective CT scanning

Devo fare ESAMI EMATICI? Quali?accesso venoso?

Devo fare ESAMI EMATICI? Quali?accesso venoso?

E se tutto è negativo…la

dimetto?

E se tutto è negativo…la

dimetto?

Indagini strumentali?

E-FAST? RX? O TC?

Indagini strumentali?

E-FAST? RX? O TC?

PIU DI DUE DISTRETTI

INTERESSATI

PIU DI DUE DISTRETTI

INTERESSATI

IPOTENSIONEIPOTENSIONE

INCOSCIENZAINCOSCIENZA

ACIDOSIACIDOSI

COAGULOPATIACOAGULOPATIA

ETA’ (68)ETA’ (68)

Sono un politrauma o

no???

Sono un politrauma o

no???