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/
Top Related