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Scott G. Sagraves, MD, FACSTrauma Medical Director
St. Lukes Hospital of Kansas City
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No financial relationships creating a conflict
of interest to report
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Define the anatomy and physiology of
Traumatic Brain Injury (TBI)
Explain the concept of the Monroe-Kellie
Doctrine
Interpret the Brain Trauma Foundationguidelines for EMS treatment of TBI
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Discuss EMS strategies for managing
injured patients
Compare and contrast City vs. Country
challenges in managing injured patients
Suggest strategies for the EMSmanagement of trauma patients
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Golden hour
30%
late
20%
immediate
50%
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0%
20%
40%
60%
80%
100%
120%
0min 30min 60min 120min 180min
Time (min)
%D
ecline
Urban
Rural
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injury related deaths are 40%higher in rural communities
than in urban areasCenter for Rural Care Fact Sheet University of North Dakota 2003
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Methods: Retrospective Review of
Autopsy/ME Database
Comparing outcomes urban SDC vs rural VT
All fatalities were reviewed ISS
Age
Cause of death
Mechanism of Injury Comorbidities
Rogers et al, Arch Surg 1997
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San Diego Vermont
Cases 248(41%) 103(72%)*
ISS 54 39*
Age 33 45*
Blunt/Pen(%) 69/31 49/51*
Rogers et al, Arch Surg 1997
*p < 0.05
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San Diego Vermont
Cases 243(40%) 23(16%)*
ISS 52 33*
Age 33 46*
Blunt/Pen(%) 61/39 96/4*
Rogers et al, Arch Surg 1997
*p < 0.05
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Rural patients are more likely to die atthe scene, are less severely injuredand are older
Rural patients surviving 24 hoursbefore death are older, less severelyinjured, have more co-morbiditiesand are more likely to die of MOSFcompared to urban patients
Rogers et al, Arch Surg 1997
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CITY COUNTRY
911 system local
Paid, staffed vehicles Trauma Centers close
Training
Lots of resources
Ground transportALS
911 system county
Volunteer Longer distances
Training difficult
Limited resources
Helicopter transport BLS
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CITY COUNTRY
C.A.B.
load n go
A.B.C.D.E.
stay n play
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Circulation & Hemorrhage control
AirwayBreathing
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AIRWAY & C-spine Control
BREATHINGCIRCULATION & Bleeding Control
DISABILITY - Neurologic AssessmentEXPOSURE - Prevent Hypothermia
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www cdc gov/Fieldtriage
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Visually inspect
Sweep clear with gloved hand
Aggressive suctioning
Avoid Hypoxemia
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http://www.firefightermedic.com/wp-content/uploads/2013/03/bvm3.jpghttp://www.911school.com/store2/product_info.php?cPath=50_53_58&products_id=121&osCsid=9rnqnigb8iteajdd5t201o5e51 -
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SevereTrauma
Bleeding -- Consumption
CRYSTALLOIDS TRANSFUSION
DILUTION HYPOTHERMIA
COAGULOPATHYM J Cohen, UCSF
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ACIDOSIS
COAGULOPATHY HYPOTHERMIA
DEATH
Triad of Death
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Maintain mission integrity:
Keep the patient alive
Recognition of the triad
Rapid Transport to the nearest
appropriate hospital (trauma
center)
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Immediate vs. delayed fluid resuscitation
for hypotensive patients with penetratingtorso injuries
Bickell WH, Wall MH, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL
Dept of Emergency Services, Saint Francis Hospital, Tulsa, OK USA
N Engl J Med 1994 Oct 27;331:1105-9
598 patients; BP < 90; prospective, randomized Standard vs. limited resuscitation (prior to OR) by EMS
2480 mLs vs. 375 mLs IV fluids
Standard: 38% mortality (p=0.04) & 30% morbidity
Limited: 30% mortality and 23% morbidity
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Normotensive = No IV fluids
Hypotensive = IV fluids until
Palpable radial pulse
Improved mentation MAP ~ 50 mm Hg; SBP ~ 80 mm Hg
Controlled IV fluid boluses
25 500 mL
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Hypotension is almost never due to braininjury or hypovolemia from brainhemorrhage.
Exsanguination can occur from scalplaceration
Hypotension (SBP < 90 for 5 min) doubles brain injury mortality (60% vs. 27%)
additional hypoxia increase mortality to 75%
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Goal:
Maintain SBP > 90 mm Hg; MAP > 65
Treatment
Correct hypotension with isotonic fluids
0.9% Normal Saline
Lactated Ringers (LR)
Consider hypertonic saline (3%) if GCS < 8 250 mL 500 mL bolus
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Established EMS system with goal ofgetting the right patient to the right placein the right amount of time
Goal Limit pre-hospital time
Transport vehicle quickest means to closestcenter
Transport to facility which has: CT scan capabilities
ICP monitoring
Neurosurgical Care
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The perfect hemostatic
dressing does not exist.
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Chitosan (anthropod skeletons) 79 97% success rate
Must adhere well to wound
Is not flexible, difficult to pack
Works best on superficial, flat wounds
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Kaolin volcanic rock Absorbs water in wound
Concentrates factors, platelets
In powder form heat created
Problem solved Gauze pads impregnated
Require 2-5 mins pressure
Activates factor XII
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ONLY PRODUCT ENDORSED BY THE
TACTICAL COMBAT CASUALTY CARE
COMMITTEE OF DoD
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MAST
Blanket or Sheet
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1 gram over 10 minutes
First dose within 3 hours of injury
Second dose: 1 gram over 8 hours
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Trauma=unstable spine injury=spinal cordinjury=permanent neurological deficit=bad.
Any additional movement of the neck/back maycause an injury that was not present immediately
following the initial traumaor it may worsen aninjury that was there prior to any subsequentmedical intervention.
Further injury is avoided by immobilizing the spine.
Immobilization of the spine is safe.
Medicolegal issues prevent us from changing.
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Pressure sores/tissue hypoxia
Good evidence that even short time periodson a board cause tissue hypoxia at contact
points as well as pressure wounds
Wounds become worse with elderly andseverely injured folks who cant readjust onboard (aka spinal cord injured patient!)
Linares HA, Mawson AR, Suarez E, Biundo JJ. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics. 1987;10:571-3.
Sheerin F, de Frein R. The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of three surfaces. J Emerg Nurs. 2007 ;33:447-50.
Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995 ;26:31-36.
Berg G, Nyberg S, Harrison P, Baumchen J, Gurss E, Hennes E. Near-infrared spectroscopy measurement of sacral tissue oxygen saturation in healthy volunteers immobilized on rigid spine boards. Prehosp Emerg Care. 2010;14:419-24.
Walton R, et al. Padded vs. Unpadded Spine Board for Cervical Spine Immobilization. AcadEmerg Med. 1995 Aug;2(8):725-8.
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Increased painHealthy subjects placed on boards developednumerous complaints when on boards for shorttimes (headaches, back, neck pain, dizziness,nausea)
Barney RN, Cordell WH, Miller E. Pain associated with immobilization on rigid spine boards. Ann Emerg Med. 1989;18:918.
Lerner EB, Billittier AJ, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization ofhealthy subjects. Prehosp Emerg Care. 1998;2:112-6
Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers.Ann Emerg Med.1994;23:48-51
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We should NOTbe immobilizingpenetrating trauma.
Increases mortality and clear supportfrom all parties involved (AANS, ACS-COT, NAEMSP,NAEMT, ATLS/PHTLS etc..)
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Rhee P, et al. 2006
57,523 trauma patients
Evaluated by: Blunt assault
Stab wounds
Gunshot wounds
Rhee P, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating
assault.J Trauma.2006;61:1166-1170
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Rates for C-spine Fx:
GSW (1.35%)
Blunt Assault (0.41%)
Stab Wound (0.12%).
Rates of Spine Cord Inj:
GSW (0.94%)
Blunt Assault (0.14%)
Stab Wound(0.11%) Rhee P, et al. Cervical spine injury is
highly dependent on the mechanism of
injury following blunt and penetrating
assault.J Trauma. 2006;61:1166-1170
Surgical stabilization:
GSW (26/158 [15.5%])
Blunt Aslt(6/19 [31.6%])
Stab Wnd (3/11 [27.8%])
No patient with
penetrating SCI
regained
significantneurologic
recovery.
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Dont get shot in the spinal cord..Neurologic deficits from penetrating
assault were established and final at
the time of presentation.Concern for protecting the neck should
not hinder the evaluation process or life
saving procedures.
Dont waste time on scene
packaging..just go.
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There are no data to support routine spineimmobilization in patients with penetratingtrauma to the neck or torso.
There are no data to support routine spinalmobilization in patients with isolated penetratingtrauma to the cranium.
Spine immobilization should never be done at
the expense of accurate physical examination oridentification and correction of life-threateningconditions in patients with penetrating trauma.
Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE. Prehospital spineimmobilization for penetrating trauma--review and recommendations from the PrehospitalTrauma Life Support Executive Committee.J Trauma.2011;71:763-9; discussion 769-70.
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Unwarranted spinal immobilization can exposepatients to the risks of iatrogenic pain, skinulceration, aspiration and respiratorycompromise, which in turn can lead to multiple
radiographs, resulting in unnecessary radiationexposure, longer hospital stay and increasedcosts. The potential risks of aspiration andrespiratory compromise are of concern because
death from asphyxiation is one of the majorcauses of preventable death in trauma patients.
Kwan I, Bunn F, Roberts I. Spinal immobilization for trauma patients. Cochrane Database of SystematicReviews. 2009;1:1-15
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Reduce amount of on-scene personnel.
Reduce amount of patients lifted fromground on LSB who are already ambulatory.
Reduce amount of awkward positionsproviders place themselves in to extricateotherwise well patients from vehicles.
Reduce scene times by eliminating timespent immobilizing to board. (cot straps arequick!...LSB strapping is NOT quick)
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Decreased awkward extrication of stable patientswho could self-extricate
Less resources/manpower needed (two folks and acot for most minor MVCs with neck pain).
Less scene time when using cot straps and not
securing head. More exposure/access to patient enroute. More comfort for patient. Saves patient from ED doc who leaves on board in
hospital.
Decrease radiological studies. Decreases cost. Decrease in resistance to placing a c-collar in elderly
or borderline patient when not mandated to use LSB.
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Despite the long-standing history and
culture of spinal immobilization with a
backboard and cervical collar, using the
best evidence available, many abroadand in the US believe the risk-benefit
analysis shows that the proven harm is
much worse than the theoretical, butunproven, benefit of the backboard.
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