Trauma and Cardiac Trauma and Cardiac ResuscitationResuscitation

Dr. Paul PageauDr. Paul PageauStaff PhysicianStaff Physician

Assistant Fellowship Director EMUSAssistant Fellowship Director EMUSDepartment of Emergency MedicineDepartment of Emergency Medicine

University of OttawaUniversity of OttawaThe Ottawa HospitalThe Ottawa Hospital

ObjectivesObjectives

General approach to General approach to Trauma/Resuscitation patients (A-B-C-Trauma/Resuscitation patients (A-B-C-D)D)

Approach to patient with multisystem Approach to patient with multisystem trauma (MVC, penetrating, and other)trauma (MVC, penetrating, and other)

Approach to asystole/V-fib/STEMI Approach to asystole/V-fib/STEMI patient and resuscitation, including patient and resuscitation, including drugs and therapeutic hypothermiadrugs and therapeutic hypothermia

Trauma code: Outline role of Trauma code: Outline role of Emergency Physician, Emergency Emergency Physician, Emergency team, TTL, and other services team, TTL, and other services

General Principles of General Principles of ResuscitationResuscitation PreparationPreparation Triage (multiple and mass Triage (multiple and mass

casualties)casualties) TeamworkTeamwork LeadershipLeadership CommunicationCommunication Crisis Resource managementCrisis Resource management Situation awarenessSituation awareness

Trauma A-B-C’sTrauma A-B-C’s

Primary SurveyPrimary Survey A – Airway and C-spineA – Airway and C-spine B – Breathing and VentilationB – Breathing and Ventilation C – Circulation and Hemorrhage C – Circulation and Hemorrhage

controlcontrol D – Disability (Neuro)D – Disability (Neuro) E – Exposure and Environment E – Exposure and Environment

control control

Adjuncts to Primary Adjuncts to Primary SurveySurvey MonitoringMonitoring CathetersCatheters eFASTeFAST Consider transfer/ Trauma CodeConsider transfer/ Trauma Code

Secondary SurveySecondary Survey

Head to Toe (finger or tube)Head to Toe (finger or tube) History and Physical examinationHistory and Physical examination Continual reassessment of Vital Continual reassessment of Vital

signssigns Complete Neuro examComplete Neuro exam Specific radiologic evaluation (CT)Specific radiologic evaluation (CT)

Code One TraumaCode One Trauma

EP on duty +- Res/students, 3 RN’s (Chart, Action/Task)EP on duty +- Res/students, 3 RN’s (Chart, Action/Task) Trauma Team Leader (Gen Surgery or Emerg staff)Trauma Team Leader (Gen Surgery or Emerg staff) Gen Surgery Sr ResidentGen Surgery Sr Resident Anaesthesia ResidentAnaesthesia Resident 2 Respiratory Therapists2 Respiratory Therapists 2 Patient Transport Workers2 Patient Transport Workers Advance care nurse practitioner – traumaAdvance care nurse practitioner – trauma Clinical manager in EDClinical manager in ED Trauma coordinatorTrauma coordinator SecuritySecurity OR is notifiedOR is notified Trauma Dept is notifiedTrauma Dept is notified

Code One TraumaCode One Trauma

TTL is EP on duty until TTL on call TTL is EP on duty until TTL on call arrives (<20min)arrives (<20min)

Gen Surg Resident may assume TTL Gen Surg Resident may assume TTL role depending on Level of trainingrole depending on Level of training

Anaesthesia takes direction from TTL Anaesthesia takes direction from TTL but mainly manages airway +- pain but mainly manages airway +- pain medicationmedication

RN’s: IV catheters, monitoring, charting, RN’s: IV catheters, monitoring, charting, other catheters, facilitating, anticipatingother catheters, facilitating, anticipating

RT’s: Airway assistance, Ventilation, RT’s: Airway assistance, Ventilation, monitoringmonitoring

Trauma Case 1Trauma Case 1Hx:Hx: 11yo ATV no helmet, Collided with tree11yo ATV no helmet, Collided with tree Altered LOC, hematoma ant scalp, Ant chest Altered LOC, hematoma ant scalp, Ant chest

contusioncontusion EMS Vitals: HR130, BP80/60, Sats 90%RA, EMS Vitals: HR130, BP80/60, Sats 90%RA,

GCS=10, PERLGCS=10, PERL Long transport from TrailLong transport from Trail IVF 1LIVF 1L

Trauma Case 1Trauma Case 1 Boarded and collared wet clothesBoarded and collared wet clothes Vitals HR120, BP90/65, Sats 90% on O2, RR25, Vitals HR120, BP90/65, Sats 90% on O2, RR25,

GCS=11, T34.8 tympGCS=11, T34.8 tymp VomittingVomitting

Primary Survey:Primary Survey: Airway: moaning, emesis on faceAirway: moaning, emesis on face Cspine protectedCspine protected Decreased A/E on Right, dull percsnDecreased A/E on Right, dull percsn Trachea midlineTrachea midline Decreased Cap refillDecreased Cap refill PERLPERL FAST pos pleural fluid, neg peritoneal fluidFAST pos pleural fluid, neg peritoneal fluid

Trauma Case 1Trauma Case 1

pt vomits just prior to ETTpt vomits just prior to ETT roll onto side and suctionroll onto side and suction pt develops pulseless VF when rollingpt develops pulseless VF when rolling defibrillate 2J/kg X1defibrillate 2J/kg X1 vitals return to baselinevitals return to baseline

Trauma Case 1Trauma Case 1

Secondary Survey:Secondary Survey: Right hemotympanumRight hemotympanum Forehead abrasion and hematomaForehead abrasion and hematoma Right chest contusionRight chest contusion Pelvis stable, Abdo softPelvis stable, Abdo soft

Disposition:Disposition: Transfer to Tertiary care/ICUTransfer to Tertiary care/ICU

Trauma Case 2Trauma Case 2

Large Community Hospital. Large Community Hospital. OB/Anaesthesia in house, Peds often in OB/Anaesthesia in house, Peds often in househouse

EMS presents unannounced with 35yr EMS presents unannounced with 35yr female MVC, VSA, 30wks + pregnant.female MVC, VSA, 30wks + pregnant.

Hx:Hx: 35 yo female. 35 yo female. 30 wks+ pregnant,30 wks+ pregnant,

Belted passenger, T-boned,Belted passenger, T-boned,.. EMS on site <5min: VSA, CPR and EMS on site <5min: VSA, CPR and

epinephrine X2, intubated, 1L NSepinephrine X2, intubated, 1L NS Arrival to ED after 25 mins downtimeArrival to ED after 25 mins downtime

Trauma Case 2Trauma Case 2

Interventions?:Interventions?: OB statOB stat Peds Peds

Primary Survey:Primary Survey: IntubatedIntubated Multiple right rib fractures – soft chest ?Air Multiple right rib fractures – soft chest ?Air

Entry on REntry on R VSA – CPR in progressVSA – CPR in progress

Trauma Case 2Trauma Case 2

Interventions?:Interventions?: perimortem C/Sperimortem C/S ?Chest tube R?Chest tube R

Secondary Survey:Secondary Survey: Pupils fixed dilatedPupils fixed dilated blood from L ear and visible brain matter R blood from L ear and visible brain matter R

skullskull Pregnant abdomenPregnant abdomen Pelvis unstablePelvis unstable

Cardiac Arrest and Cardiac Arrest and ResuscitationResuscitationPrinciples:Principles:Chain of survival:Chain of survival: Recognition and activationRecognition and activation Early CPREarly CPR Rapid defibrillationRapid defibrillation Advanced life supportAdvanced life support Integrated post-cardiac arrest Integrated post-cardiac arrest

carecare

Cardiac arrestCardiac arrest

Call for help, Defibrillator, CPRCall for help, Defibrillator, CPR Shockable rhythm? Shockable rhythm? 200J 200J CPR CPR Asystole/PEA Asystole/PEA CPR CPR Epi 1mg q3-5min, Epi 1mg q3-5min,

Atropine 1mg q3-5min X3Atropine 1mg q3-5min X3 Check for shockable rhythm q2min CPRCheck for shockable rhythm q2min CPR Treat contributing factors (H’s and T’s)Treat contributing factors (H’s and T’s) Consider antiarrhythmics: amiodarone Consider antiarrhythmics: amiodarone

300mg, or Lidocaine 1mg/kg, 300mg, or Lidocaine 1mg/kg, Consider magnesium 1 – 2 gms for Consider magnesium 1 – 2 gms for

torsadestorsades

ROSCROSC

Evaluate for STEMI Evaluate for STEMI PCI/code PCI/code STEMISTEMI

In comatose pts evaluate for In comatose pts evaluate for therapeutic hypothermiatherapeutic hypothermia

Stabilize, monitor, definitive care Stabilize, monitor, definitive care

ObjectivesObjectives

General approach to General approach to Trauma/Resuscitation patients (A-B-C-Trauma/Resuscitation patients (A-B-C-D)D)

Approach to patient with multisystem Approach to patient with multisystem trauma (MVC, penetrating, and other)trauma (MVC, penetrating, and other)

Approach to asystole/V-fib/STEMI Approach to asystole/V-fib/STEMI patient and resuscitation, including patient and resuscitation, including drugs and therapeutic hypothermiadrugs and therapeutic hypothermia

Trauma code: Outline role of Trauma code: Outline role of Emergency Physician, Emergency Emergency Physician, Emergency team, TTL, and other services team, TTL, and other services