Trauma: The Golden Hour

Trauma:Trauma:The Golden HourThe Golden Hour

Dennis Kim MD Dennis Kim MD FRCS(C)FRCS(C)

General SurgeryGeneral Surgery

Trauma & Critical Care Trauma & Critical Care POS Core POS Core

Lecture SeriesLecture Series

February 17 2009February 17 2009

ObjectivesObjectives

concept of a golden hourconcept of a golden hour

pathophysiology of shock in the pathophysiology of shock in the trauma patienttrauma patient

resuscitation according to ATLS resuscitation according to ATLS principlesprinciples

overviewoverview specificsspecifics

The Golden HourThe Golden Hour

originated by R Adams Cowleyoriginated by R Adams Cowley

first sixty minutes after the first sixty minutes after the occurrence of multi-system traumaoccurrence of multi-system trauma

victim's chances of survival are victim's chances of survival are greatest greatest if they receive definitive if they receive definitive care in the OR within the first hour care in the OR within the first hour after a severe injuryafter a severe injury


recently, the validity of the “golden recently, the validity of the “golden hour” as a rigidly defined timeframe hour” as a rigidly defined timeframe scrutinizedscrutinized

core principle of rapid intervention core principle of rapid intervention in trauma cases remains universally in trauma cases remains universally acceptedaccepted


"There is a golden hour between life "There is a golden hour between life and death. If you are critically injured and death. If you are critically injured you have less than 60 minutes to you have less than 60 minutes to survive. You might not die right then; survive. You might not die right then; it may be three days or two weeks it may be three days or two weeks later -- but something has happened later -- but something has happened in your body that is irreparable."in your body that is irreparable."

- R Adams Cowley- R Adams Cowley


Time and Trauma OutcomesTime and Trauma Outcomes

no convincing studies that time to no convincing studies that time to treatment consistently leads to better treatment consistently leads to better outcomeoutcome

outcome related to many factors outcome related to many factors including reduced time between injury including reduced time between injury and definitive careand definitive care

Ann Surg. 2003;237(2):153-60 Ann Surg. 2003;237(2):153-60

1. What is the most common 1. What is the most common cause of shock in the cause of shock in the trauma patient?trauma patient?

septicseptic

B) cardiogenicB) cardiogenic

C) hemorrhagicC) hemorrhagic

D) neurogenicD) neurogenic

2. The most easily 2. The most easily reversible cause of shock in reversible cause of shock in the trauma patient is:the trauma patient is:

A) hemorrhagicA) hemorrhagic

B) neurogenicB) neurogenic

C) tension pneumothoraxC) tension pneumothorax

D) cardiac tamponadeD) cardiac tamponade

3. The most commonly 3. The most commonly injured solid intraabdominal injured solid intraabdominal organ in blunt trauma is:organ in blunt trauma is:

A) liverA) liver

B) spleenB) spleen

C) kidneyC) kidney

D) small bowelD) small bowel

4. The bloody vicious cycle 4. The bloody vicious cycle of trauma refers to:of trauma refers to:

A) bleeding, hypothermia, and acidosisA) bleeding, hypothermia, and acidosis

B) bleeding, hyperthermia, acidosisB) bleeding, hyperthermia, acidosis

C) transfusion, hypothermia, acidosisC) transfusion, hypothermia, acidosis

D) transfusion, hypothermia, alkalosisD) transfusion, hypothermia, alkalosis

5. Hemorrhagic shock is 5. Hemorrhagic shock is usually caused by bleeding usually caused by bleeding into or from:into or from:

A) abdomenA) abdomen

B) pelvisB) pelvis

C) chestC) chest

D) headD) head

E) all of the aboveE) all of the above

F) A,B,CF) A,B,C


Shock PathophysiologyShock Pathophysiology

inadequate organ inadequate organ perfusionperfusion and and tissue tissue oxygenationoxygenation

3 factors determine:3 factors determine:

1. 1. oxygen contentoxygen content2. 2. oxygen deliveryoxygen delivery3. 3. distribution distribution


Shock PathophysiologyShock Pathophysiology

prolonged hypoperfusion creates a prolonged hypoperfusion creates a vicious cycle of ischemia and shockvicious cycle of ischemia and shock

2 most important steps in managing 2 most important steps in managing shock:shock:

1. recognition1. recognition2. treatment2. treatment


Rapid ResuscitationRapid Resuscitation

restores circulating volumerestores circulating volume improves oxygen deliveryimproves oxygen delivery prevents cellular ischemia and tissue prevents cellular ischemia and tissue

necrosisnecrosis prevents onset of secondary cellular prevents onset of secondary cellular

injuryinjury prevents onset of MODSprevents onset of MODS


What should we be doing?What should we be doing?

Rapid assessmentRapid assessment

Resuscitation and stabilizationResuscitation and stabilization

Definitive management/TransferDefinitive management/Transfer

ATLS

ATLS OverviewATLS Overview

The ATLS ConceptThe ATLS Concept

Primary SurveyPrimary Survey

AdjunctsAdjuncts

Secondary SurveySecondary Survey

Definitive Care/TransferDefinitive Care/Transfer


The ATLS ConceptThe ATLS Concept

treat life threatening injuries as treat life threatening injuries as they are identifiedthey are identified

assessment/diagnosis and assessment/diagnosis and resuscitation are simultaneousresuscitation are simultaneous


Primary SurveyPrimary Survey

AA AirwayAirway BB BreathingBreathing CC CirculationCirculation DD (neurologic) Disability(neurologic) Disability EE Exposure / EnvironmentExposure / Environment

AMPLEAMPLE


AdjunctsAdjuncts

Urinary catheterUrinary catheter NG tubeNG tube XraysXrays


Secondary SurveySecondary Survey

Thorough “head to toe” assessmentThorough “head to toe” assessment

Definitive Care/TransferDefinitive Care/Transfer

Deadly DozenDeadly Dozen

Lethal SixLethal Six airway obstructionairway obstruction tension PTXtension PTX open PTXopen PTX flail chestflail chest massive massive

hemothoraxhemothorax cardiac tamponadecardiac tamponade

Hidden SixHidden Six pulmonary contusionpulmonary contusion diaphragmatic diaphragmatic

tear/rupturetear/rupture tracheobronchial tracheobronchial

injuryinjury blunt cardiac injuryblunt cardiac injury thoracic aortic thoracic aortic

disruptdisrupt esophageal injuryesophageal injury

ATLS SpecificsATLS Specifics

AA - airway - airway ((with C-spine protectionwith C-spine protection))

PreventablePreventable Deaths from Airway Deaths from Airway ProblemsProblems failure to recognize need for airwayfailure to recognize need for airway inability to establish airwayinability to establish airway failure to recognize incorrect placementfailure to recognize incorrect placement displacement of previously placed airwaydisplacement of previously placed airway failure to recognize need for ventilationfailure to recognize need for ventilation aspiration of gastric contentsaspiration of gastric contents

Airway AlgorithmAirway Algorithm


AA - airway - airway ((with C-spine protectionwith C-spine protection))

Rapid Sequence Intubation (RSI)Rapid Sequence Intubation (RSI) preoxygenationpreoxygenation cricoid pressurecricoid pressure sedation (etomidate, midazolam)sedation (etomidate, midazolam) succhinylcholinesucchinylcholine orotracheal intubationorotracheal intubation cuff inflation, confirmation of positioncuff inflation, confirmation of position release of cricoid pressurerelease of cricoid pressure


Alternative Alternative AAirway Devices/Optionsirway Devices/Options nasotracheal intubationnasotracheal intubation LMA / intubating LMALMA / intubating LMA Glide scopeGlide scope fiberoptic intubationfiberoptic intubation surgical airwaysurgical airway

needleneedle

percutaneouspercutaneousopenopen


Alternative Alternative AAirway Devices/Optionsirway Devices/Options


Surgical Surgical AAirwayirway


AA - airway ( - airway (with C-spine protectionwith C-spine protection))

ATLS: ATLS: lateral C spine filmlateral C spine film complete C spine series during secondary complete C spine series during secondary

surveysurvey

Current practice: Current practice: in ER assume C spine injuryin ER assume C spine injury no C spine films in ERno C spine films in ER CT scan of C spine with reconstructionsCT scan of C spine with reconstructions


AA - airway ( - airway (with C-spine with C-spine protectionprotection))

““Clearing” the C spine Clearing” the C spine (multiple trauma (multiple trauma patient)patient) rarely done in ER (except fully conscious, no rarely done in ER (except fully conscious, no

distracting injury)distracting injury) CT scan with reconstructionsCT scan with reconstructions Further studiesFurther studies

MRIMRI Flexion - Extension viewsFlexion - Extension views


BB – breathing – breathing oxygenationoxygenation ventilationventilation monitoringmonitoring

clinical (auscultation)clinical (auscultation)

OO22 saturation saturation

EtCOEtCO22

ABG’sABG’s


CC - circulation (shock management) - circulation (shock management)

recognition and resuscitation from recognition and resuscitation from shockshock

post traumatic shock is hemorrhagic post traumatic shock is hemorrhagic shock shock until proven otherwiseuntil proven otherwise

Shock

Obstructive

Tension pneumo

Nonobstructive

Cardiac tamponade

Distributive Nondistributive

Sepsis/SIRS

Anaphylaxis

Neurogenic

Hypovolemic

Cardiogenic

Hemorrhagic

Third spacing



Classification and mechanisms of shockClassification and mechanisms of shock obstructiveobstructive

tension pneumothoraxtension pneumothorax cardiac tamponadecardiac tamponade

Tension pneumothorax is the most EASILY corrected cause of shock



Classification and mechanisms of shockClassification and mechanisms of shock distributivedistributive

spinal cord injuryspinal cord injury sepsissepsis anaphylaxisanaphylaxis



Classification and mechanisms of shockClassification and mechanisms of shock cardiogeniccardiogenic

myocardial contusionmyocardial contusion valvular disruptionvalvular disruption ischemic injuryischemic injury



Classification and mechanisms of shockClassification and mechanisms of shock hypovolemichypovolemic

blood lossblood loss fluid lossfluid loss



ACS Classes of Hemorrhage ACS Classes of Hemorrhage classes I - IVclasses I - IV based on estimated blood loss and effect based on estimated blood loss and effect

on vital signson vital signs


C – C – circulation (shock circulation (shock management)management)

STOP STOP the BLEEDINGthe BLEEDING External blood lossExternal blood loss Internal blood lossInternal blood loss

REPLACEREPLACE blood loss blood loss


C – C – circulation (shock management)circulation (shock management)

Vascular accessVascular access

Direct pressureDirect pressure

Fluid administrationFluid administration

Assessment of responseAssessment of response


C – C – circulation (shock management)circulation (shock management)

Fluid AdministrationFluid Administration

ATLS: initial 2 litre bolus of ATLS: initial 2 litre bolus of warmedwarmed Ringer’s (NS)Ringer’s (NS)



CrystalloidCrystalloid IsotonicIsotonic HypertonicHypertonic

ColloidColloid AlbuminAlbumin Starch (Pentaspan, Voluven)Starch (Pentaspan, Voluven)

ATLS SpecificsATLS SpecificsFluid Administration - which fluid?Fluid Administration - which fluid?

CrystalloidCrystalloid massive fluid administrationmassive fluid administration diffuse edema (?worsens cerebral edema)diffuse edema (?worsens cerebral edema) ?contributes to “compartment syndrome”?contributes to “compartment syndrome”

ColloidColloid no demonstrated benefit (?harm, SAFE trial)no demonstrated benefit (?harm, SAFE trial) costliercostlier

Hypertonic saline (3%, 7.5% =/- dextran)Hypertonic saline (3%, 7.5% =/- dextran) no demonstrated benefit (trial in progress)no demonstrated benefit (trial in progress) hypernatremiahypernatremia



Blood replacementBlood replacement type Otype O type specifictype specific fully crossmatchedfully crossmatched



Role of Factor VIIaRole of Factor VIIa initially used for hemophiliainitially used for hemophilia initiates thrombin formation by binding with initiates thrombin formation by binding with

exposed tissue factorexposed tissue factor reverses coagulopathyreverses coagulopathy use after use after

surgically accessible surgically accessible bleeding controlled bleeding controlled

coag factors and plateletscoag factors and platelets



Role of Factor VIIaRole of Factor VIIa parallel RCT’s in blunt/pen trauma parallel RCT’s in blunt/pen trauma

((JTrauma 05JTrauma 05) decreased RBC use in ) decreased RBC use in blunt trauma better outcome blunt trauma better outcome in coagulopathic patients (CCM 06) in coagulopathic patients (CCM 06)

better outcome in TBI (better outcome in TBI (NEJM 05NEJM 05)) multiple case reports/series showing multiple case reports/series showing

benefit in reversal of coagulopathy benefit in reversal of coagulopathy and lower transfusionand lower transfusion



Stop InternalInternal Bleedingchest, abdomen, pelvis


Recognition of thoracic Recognition of thoracic hemorrhagehemorrhage clinicalclinical

CXRCXR

Chest tube(s)Chest tube(s)


Recognition of abdominal Recognition of abdominal hemorrhagehemorrhage clinicalclinical FASTFAST DPLDPL laparotomylaparotomy


Recognition of pelvic hemorrhageRecognition of pelvic hemorrhage clinicalclinical

pelvic x-raypelvic x-ray

CT scanCT scan

Damage Control LaparotomyDamage Control Laparotomy

Part 1Part 1 stop all overt arterial bleedingstop all overt arterial bleeding pack other bleeding pack other bleeding control contaminationcontrol contamination modified closuremodified closure

Damage Control LaparotomyDamage Control Laparotomy

Part 2Part 2 return to ICU for warming, return to ICU for warming,

correction of coagulation and correction of coagulation and acidosisacidosis

Part 3Part 3 return to OR for definitive closurereturn to OR for definitive closure

ATLS SpecificsATLS SpecificsDD – (neurologic) Disability – (neurologic) Disability

ATLS: rapid recognition of lateralizing ATLS: rapid recognition of lateralizing injury (potentially surgically injury (potentially surgically correctable)correctable)

confirmation by CT scanconfirmation by CT scan emergency craniotomy for drainageemergency craniotomy for drainage


EE - exposure / environment - exposure / environment remove clothingremove clothing keep covered between examinations keep covered between examinations

(hypothermia)(hypothermia) logrolllogroll full examination of extremitiesfull examination of extremities

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Trauma: The Golden Hour

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