Trauma Resuscitation

Shelley Atkinson RN, MSN, ANP-BC, ACNP- BC

Objectives• Identify the correct sequence of priorities for

assessment of a multiple injury trauma patient.

• Identify the principles outlined in the primary and secondary evaluation surveys to the assessment of a multiple injury patient.

• Identify guidelines and techniques in the initial resuscitative and definitive-care phases of treatment of a multiple injury patient.

Injury Statistics

• Leading cause of death for ages 1-44• $ 500 billion dollar annual cost• Estimated 20-50 million injuries occur per year

(40 % of emergency room visits)• Leading causes of trauma are motor vehicle

crashes, falls, and assaults

Trimodal Death Distribution

• Death due to injury occurs in one of three periods or peaks

• Care provided during each of these periods impacts patient outcomes

Trimodal Death Distribution• First peak – occurs within seconds to minutes

of injury• Second peak – occurs within minutes to

several hours following injury• Third peak – occurs several days to weeks

after initial injury

Advanced Trauma Life Support (ATLS)Assess the patient’s condition rapidly and

accuratelyResuscitate and stabilize the patient according

priorityDetermine if patient’s needs exceed a facility’s

resources/or doctor’s capabilitiesArrange for transfer (what, where, when, who,

and how)

ATLS

• Assure that optimum care is provided and level of care does not deteriorate at any point during evaluation, resuscitation, or transfer process

What is a Level One Trauma Center?

A hospital equipped to provide comprehensive emergency medical services to patients suffering traumatic injuries.

Level One CriteriaAirway/Breathing• Unstable airway/unsecure airway• Patients with severe maxillofacial injuries• Patients requiring immediate airway

intervention• Facial burns / suspected inhalation injury• Moderate to severe Respiratory distress• Sub Q air in face, neck, or chest

Level One Criteria

Circulation• Systolic BP < 90mmHg or HR > 120• Witnessed cardiac arrest from trauma• Uncontrolled/Arterial Bleeding with shock• Spinal/Neurogenic Shock

Level One CriteriaCNS• GCS ≤ 8• Head injury with LOC > 5 min • Known spinal cord injury• Neurologic deficits with suspected spinal cord

injury (any level)

Level One CriteriaChest/Abdomen/Pelvis• Chest/Abdominal/Pelvic Injury with shock• Chest wall injury– Flail chest– Sucking chest wound– Subcutaneous air

• Pregnancy ≥ 24 weeks with significant mechanism of injury

Level One Criteria

Extremities• Multiple long bone fractures with shock• Mangled Extremity or Amputation– above wrist/ankle

Level One Criteria

Mechanism of Injury• Penetrating trauma to the head, face, torso

(chest, abdomen, buttocks, back)• Ejection from vehicle • Fall from 20 or more feet with presence of

other Level I criteria• Electrocution/Electrical Injury with entry/exit

wounds

Level One Criteria

Mechanism of Injury• Burns > 20% TBSA or burns combined with any

other injury• Massive crush injury

Pre-hospital care

Initial Assessment

Primary survey and resuscitation of vital functions are done simultaneously.

A team approach

Primary SurveyABCDEs

• Airway with cervical spine protection• Breathing• Circulation with hemorrhage control• Disability: Neurologic status• Exposure/Environment

What is the number one priority during the initial assessment of a

trauma patient?A. AirwayB. AirwayC. AirwayD. All of the above

Airway Obstruction RecognitionLook

• Agitation/Obtunded• Decreased air movement• Retraction• Deformity• Airway debris

Listen

• Normal speech- no obstruction

• Noisy breathing – obstruction

• Gurgle• Stridor• Hoarseness

Inadequate BreathingLook• Cyanosis• Change in Mental Status• Chest asymmetry• Tachypnea• Neck vein distention• ParalysisFeel• Sub Q emphysema/chest wall crepitus• Tracheal deviation

Listen• “I can’t breathe”• “I am dying”• Stridor, wheezes• Decreased or absent breath

sounds

Which way for the Airway?

Rapid Sequence Intubation• Be prepared to perform a surgical airway in

the event that airway control is lost• Pre-oxygenate patient with 100% oxygen• Administer analgesic / sedative (IV) if feasible• Apply pressure over cricoid cartilage – Debatable

• Administer a paralytic IV• Perform chin lift/jaw thrust

Rapid Sequence Intubation

• After the patient relaxes, intubate orotracheally

• Inflate cuff and confirm placement – auscultate and determine CO2 in exhaled air

• Release cricoid pressure• Ventilate• CXR

Adjuncts to Primary Survey • ECG• CO2 detector• Pulse oximetry• Vital Signs

Primary SurveyCirculation with Hemorrhage Control

• Control hemorrhage• Activate trauma (Massive Transfusion Protocol)– 6U pRBC, 4U FFP, 1 Platelets– MD activation only

• Judicious use of crystalloid

6 areas potential blood loss

• Chest• Abdomen• Retroperitoneum• Pelvis• Long bones / Soft tissue• Scalp• …the ground

Trauma • Majority deaths occur in 1st few hours after

injury• Hemorrhage largest % deaths within 1st hour• Hemorrhagic shock and exsanguination– 80% deaths in OR– 50% deaths 1st 24 hrs after injury

• Very few hemorrhage deaths after 1st 24 hours• Only CNS injury more lethal

Special Considerations In Diagnosis and Treatment of Shock

• Age• Athletes• Pregnancy• Medications• Hypothermia• Pacemakers

Vascular Access

• 2 large-caliber, peripheral IVs• Central access– femoral– jugular– subclavian

• Intraosseous• Obtain blood for crossmatch• Trauma panel – CBC, BMP, coags

Hemorrhagic ShockClass I Class II Class IIIClass IV

EBL <750 750-1500 1500-2000 >2000

HR <100 >100 >120 >140

BP NL NL LOW LOW

UO >30 20 - 30 5 - 15 MIN

ACS-COT 1993

Direct Effects of Hemorrhage

• Class I – (up to 15% blood volume loss)Exemplified by the patient that has donated one unit of blood• Class II – (15% - 30% blood volume loss)Uncomplicated hemorrhage for which crystalloid fluid resuscitation is required

Direct Effects of Hemorrhage• Class III – (30% - 40% blood volume loss)Complicated hemorrhagic state in which at least crystalloid infusion is required and perhaps also blood replacement• Class IV – (more than 40%)Considered a pre-terminal event, and unless very aggressive measures are taken, the patient will die within minutes

Fluid Resuscitation

• Balance organ perfusion with risk of re-bleeding– may reverse vasoconstriction of injured vessel– Dislodge early clot– Dilute coagulation factors– Cool patient– Induce visceral swelling

Too much fluid?

Adequacy of ResuscitationClinical Variables

• Mentation• Pulse, pulse pressure, BP• Urine output• Clot formation• Temperature• Lactate/base deficit

Primary Survey - DisabilityNeurologic Evaluation

• Baseline neurologic evaluation• GCS scoring• Pupillary response

**Observe for neurologic deterioration

Head Trauma

• Severe CHI (GCS < 9) vulnerable to secondary brain injury

• Hypotension doubles mortality• Hypoxia and hypotension increases mortality

by 75%• Normovolemia goal (dehydration harmful)• Hypertonic saline or Osmotic Agent (mannitol)

Head Trauma

• Hyperventilation used cautiously– only used if patient rapidly deteriorates

• PCO2 no lower than 30-35

• Prolonged hyperventilation can produce cerebral ischemia and secondary brain injury

• Mannitol useful– after adequate volume resuscitation

Spinal Cord Injury

• Neurogenic Shock– Consider hemorrhage first…

• Maintain spine immobilization • Fluid or no fluid?• Vasopressors

Septic Shock

• Uncommon immediately after injury• May occur several hours after injury

(especially if transfer to emergent facility delayed)

• May occur in penetrating abdominal injuries– contamination of intestinal contents into

peritoneal cavity

Primary Survey - Exposure/Environmental Control

• Completely undress the patient• Prevent hypothermia

Deadly Triad

• Hypothermia• Acidosis• Coagulopathy

Hypothermia (HT)• Frequent in trauma/massive transfusions• Trauma-related HT considered poor prognostic sign• Mortality directly to degree and duration• Inhibits coagulation factor synthesis, prolongs PT and

PTT• Severely affects platelet count and function• Attenuates vital CV compensatory responses,

predisposes to arrhythmias

Re-warming

• Aggressive therapy associated with significant decrease in:– blood loss– fluid requirements– organ failure– LOS in ICU– mortality rate

Secondary Survey

• Begins after ABCDE is completed• Resuscitative efforts underway• Each region of the body is completely

examined

Trauma imaging• Chest x-ray• Pelvis x-ray • FAST– focused assessment sonography in trauma

• DPL (center-dependent)– diagnostic peritoneal lavage

• CT scan– Traumagram

Adjuncts Secondary Survey

• Foley• NGT• ABG/lactate– If actively resuscitating

Primary Goal of Initial Operation for a Trauma Patient

Damage Control• Hemorrhage Control• Contamination

Case Study #120 year old male, unrestrained driver, in a motor

vehicle that collides into a large tree. +LOC at the scene and unresponsive. Starred windshield. Life flight transported to VUMC.

VS: 120/70 mm Hg, HR= 110-115, RR= 15Receiving oxygen 100% NRB

Question #1

What is the number one priority during the initial assessment of this trauma patient?

1-Airway2-Breathing3-Circulation4-Disability

Question #2What Level One Criteria does the patient meet?1- GCS < or = 82- Head injury with LOC > 5 min3- moderate to severe respiratory distress4- all the above

Question #3 True or False.The patient’s need for airway protection and ventilation is due to unconsciousness.1- True2- False

Question #4 Which two steps listed below are early steps in the RSI procedure?1- Pre-oxygenate with 80% oxygen & apply cricoid pressure2- perform chin lift/jaw thrust to open airway& pre-oxygenate with 100% oxygen3- administer a paralytic & ventilate

Question #5 How do I know the ETT is in the correct position?1- presence of CO2 in the end tidal CO2 detector only?2- equal breath sounds bilaterally and gurgling in the epigastrium3- presence of CO2, equal bilateral breath sounds and CXR

Case Study #2• 20 year old male assaulted. GSW to right

chest and left lower extremity. Patient is c/o chest pain, SOB, and left lower extremity pain

• HR= 110; BP=120; RR = 30; SaO2= 90% on 100 % NRB; No BS on Right

Question #1 True or False.This patient does not meet Level One Criteria.

1- True2- False

Question #2 What trauma imaging is needed for this patient?1- CXR only2- CT of the chest3- CXR, CT chest/abd/pelvis, Left femur XR4- Head CT

What is wrong with this CXR?

Question #3 What do you think is wrong with this patient based on the CXR provided?1-labored breathing due to pain2-spleen laceration3-pneumothorax 4- hemothorax

Question #4 What should be assessed in the secondary survey?1-pulses of right leg only2-roll the patient for posterior check3-roll patient over (posterior check) and assess pulses (Fem, DP,PT)4-secondary survey excluded because the patient states, “I am fine”

Case Study #318-20 year old male unrestrained passenger. Car hit a bridge. Driver DOA. Reported by EMS, “Initially awake, not acting right”. Gradually more confused & verbally uncooperative. 2L NS in air craft. BP=110 and decreasing. HR=120. RSI per life flight.

Question #1 What signs/symptoms are the patient exhibiting that he needs resuscitation?1- decreased mentation2- increasing HR and decreasing BP3- Both

Question #2 The patient has increasing HR =130s BP= 84PWhat stage of shock is the patient in?1- Stage 12- Stage 23- Stage 34- Stage 4

Question #3 The patient was given 2L of NS during his flight and was unresponsive to this. What is the next step? BP 84P HR=1301- order a 3rd liter of crystalloid2- order 2 U PRBCs3- do nothing4- give 4 FFP

Question #4 What trauma imaging is needed at this time? Secondary survey noted left lower abdominal ecchymosis.1- CXR2- CT chest/abd/pelvis3- FAST exam4- one and two only

Question #5 True or False.

A FAST exam (focused assessment sonography)is used to rapidly identify hemorrhage or potential hollow viscous injury

1-True2-False

Question #6 FAST study positive for a large amount of fluid in the abd. What intervention is needed for the patient at this time?1- Go to the operating room2- Activate the trauma exsanguination protocol3- Go immediately to CT scan4- Both one and two

Question #7 What is the trauma exsanguination protocol or Massive transfusion protocol?1- 2 L crystalloid2- 2 U PRBC3- 2 L crystalloid and 2 U PRBC4- 6 U PRBC, 4 U FFP, 1 pack plts

References• Acute Trauma Life Support Course – Retrieved from American

College of Surgeons Website http://www.facs.org/trauma/atls/information.html on July 1, 2012.

• Guillamondegui, Oscar MD, MPH, FACS, Associate Professor of Surgery, Medical Director, Trauma ICU, Director of Trauma Education, Vanderbilt University Medical Center.

• Atkinson, S., Collins, N., Martin, M., Morton, M., Marshall, K. (2012) Outcomes of Adding ACNPs to a Level One Trauma Service with the Goal of Decreased Length of Stay and Improved Patient, Physician and Nursing Satisfaction: A pilot study.