The hypotensive trauma patient
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Transcript of The hypotensive trauma patient
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/