ben edwards 11 th feb 2014

Ben Edwards11th Feb 2014

Major Trauma

Major trauma networksTrauma team Initial Assessment and Management

<c>ABCDEDamage control resuscitation

Hypotensive & haemostatic resuscitation Damage control surgery

Emergency Admissions:A journey in the right direction?A report of the National Confidential Enquiry

into Patient Outcome and Death (2007)

Trauma: Who cares?

A report of the National Confidential Enquiry into Patient Outcome and Death (2007)

NCEPOD publish “Trauma: who cares?” in 2007 Major criticisms of current delivery of

trauma care Keith Willett appointed National

Director of Trauma Care in 2009 National Major Trauma Centre model

of care started April 2012 Full designation of major trauma

centres in April 2013 Overseen by regional trauma networks

To understand why change was needed must understand who is affected

Predominantly young people of working age Become tax consumers instead of tax

contributorsUnnecessary loss of life

20 lives/yr in Yorkshire & Humber region

Injury

Nearest A&E unit

Tertiary referral centre

Local hospitals Lack of specialist services

▪ Cardiothoracic▪ Vascular▪ Neurosurgery▪ Interventional Radiology

Necessitates transfer Causes delay Delay and transfer = worse outcomes

Q: What is a trauma network?

A: a collaboration between providers and commissioners to deliver optimal major trauma care services in a geographical area.

It includes : Major Trauma CentresPre-hospital CareAll other hospitals that deal with trauma – Trauma Units and local A&EsRehabilitation

A network is expected to improve outcomes for patients with Major Trauma through: “Better co-ordination of care where patients are

moved in a timely manner to the location best able to provide for their needs.” ▪ This applies to every stage from initial care to

rehabilitation. Improving the quality of care of the severely

injured patient at every stage of the pathway

2011 SCHARR research estimates that between 5-15% more lives could be saved. In Yorkshire and the Humber = 28 - 33 per year.

Y&H Regional Trauma Network would be cost effective if effective implementation costs less than £6–7 million

▪ (Source: Cost Effectiveness of Regional Networks for Major Trauma in England 2011)

LOS reduction of 4 days = £5 million saving per annum earlier transfers more rapid and definitive care fewer complications

▪ (Source: NCEPOD Regional trauma system guidance for commissioners 2009)

Reduction in the cost to the taxpayer more people returning to non-dependent life reduced disability increased returns to work fewer demands on social care

i.e. More people that pay tax rather than consume taxes!

Tariff for patient care = income Previously more injuries = the same money Not rewarded for multiple operations etc.

Best practice tariff (BPT) change that Multiple injuries = additional money (+

£1500) Trauma patients now bring in more money But only if certain criteria are fulfilled

Loss of complex patients = loss incomeBut same levels of staffing required

Loss of skills & training

Lack of motivation to maintain standards of trauma care

Pathway Phasing

Development to April 2014

Current

Pathway

Phase 1

From April 2012

Phase 2

From April 2013

Phase 3

From April 2014

Pre hospital triage tool Bypass of trauma units for patients who

trigger Experience paramedic in control room to

facilitate process If patient unstable or >45 minutes from

MTC consider going straight to trauma unit Development of ‘Stop, Sort, Go’ protocol

Trauma Scoring Systems

The need to classify injuries objectively is fundamental to the delivery of trauma care (and its evaluation) Allows data collection TARN Money Comparisons between centres

Physiological Trauma Score (TS) Revised Trauma Score (RTS)

Anatomical Injury Severity Score (ISS) Abbreviated Injury Scale (AIS)

▪ Not all injuries apparent at presentation

Respiratory rateRespiratory expansionSystolic BPCapillary refill timeGCS

Used to calculate need for transferRelates to mortaility

Weights more to head injury GCS Systolic BP RR

Limitations in assessing GCS Alcohol, illicit drugs Can substitute best motor response

Simple numerical method for grading and comparing injuries by severity.

Originally intended for use with vehicular injuries

Grades injuries on an scale ranging from 1 (minor) to 6 (lethal)

Does not reflect combined effects multiple injuries

Basis of ISS

Used in calculation of BPT Sum of squares of the highest AIS grade in

the 3 most severely injured body regions. Six body regions are defined

thorax, abdomen and visceral pelvis, head and neck, face, bony pelvis and extremities, and external structures.

Only one injury per body region is allowed. The ISS ranges from 1-75, and an ISS of 75 is assigned to anyone with an AIS of 6.

Trauma team allows for horizontal assessment of:<C> = Control of exsanguinating haemorrhageA = Airway with C-spine protectionB = Breathing with ventilationC = Circulation with haemorrhage controlD = Disability: Neurologic statusE = Exposure / Environment

Direct pressureIndirect pressureElevateTourniquetHaemostatic agents

Don’t forget scalp wounds

CAT Tourniquet

Quick to use Apply band around

limb Twist ‘windlass’

until arterial bleeding stops

Document time of application

CELOX GauzeGauze dressing impregnated with chitosan (shrimp shells)

Bonds to specific sites on red blood cells and platelets, forming a gel like clot

Stuff/pack into wound and apply direct pressure over

Time critical that the airway is secured as rapidly as possible if GCS<9 National standard is <30mins Facilitates rapid transfer for WBCT Direct link to neurological

outcome

But the trauma airway is likely to be difficult NAP4 also shows that airway

complications are most likely to occur in the ED

Inability to maintain and protect own airway regardless of conscious level

Inability to maintain adequate oxygenation with less invasive manoeuvres

Inability to maintain normocapnia (spontaneous PaCO2 <4.0 kPa or >6.0 kPa)

GCS ≤8 Patients undergoing transfer with:

Deteriorating conscious level (≥2 points on motor scale)

Significant facial injuries Seizures.

(See NICE Guidelines for intubation and ventilation in the presence of brain injury)

Haemorrhagic shock, particularly in the presence of an evolving metabolic acidosis.

Agitated patient (hypoxia & hypovolaemia are prime causes of agitation)

Multiple painful injuries (humanitarian) Transfer to another area of the hospital

(e.g. vascular Angio/theatres/GITU)

Recommend modified RSI Assume c-spine is unstable In line immobilisation

▪ Remove front of hard collar (occludes access to cricothyroid membrane)

Elective use of bougee Uncut ETT if any

burns/blasts Tape rather than tie to

reduce venous pressure

Careful dose titration required (hypovolaemia and acidosis).

If head injury is suspected attenuate the stress response to laryngoscopy (alfentanil 10µg kg-1 is effective)

Ketamine is the agent of choice in the haemodynamically unstable patient not contraindicated in brain injury (minimises

hypotension in those with hypovolaemia and abnormal cerebral autoregulation)

Etomidate not recommended due to adrenal suppression Contra-indicated in head injury (uncouples cerebral

blood flow and metabolism)

Aim VT 6-8 ml/kg, Pmax< 30, arterial pC02 4.5 – 5 kPa

Consider inserting an arterial line Changing airway pressure may

indicate a change in compliance pneumothorax or lung injury.

Maintain anaesthesia using volatile or infusions (i.e. Propofol/Alfentanyl)

Volatile anaesthesia can increase cerebral blood flow &ICP < 1 MAC, switch to i.v. agents as

soon as possible.

• Immediately life threatening injuries requiring urgent intervention

Tension & open pneumothorax▪ Decompression (needle or thoracostomy)

Haemothorax▪ Drainage and volume replacement

Flail chest▪ Rib fracture fixation

Tamponade▪ Temporising pericardiocentesis ▪ Definitive or resuscitative thoracotomy

Imaging Obtain CXR at the earliest

opportunity rib fractures and

pneumothorax (particularly anterior) may be missed and only detected clinically or on CT scan –don’t delay CT

Chest ultrasound is useful investigation for pneumothorax and tamponade

 Chest drain without the actual intercostal catheter: The wound is left open.

Enables rapid decompression of a tension pneumothorax in an intubated patient Positive pressure ventilation prevents

the thoracostomy wound from acting as an open, ‘sucking’, chest wound.

The key is to turn the tap off! In the interim, the core principles are that of Damage Control Resuscitation

Concepts primarily conceived in the military Improved survival from battlefield trauma Landmark paper from Jansen et al

Jansen J et al. Damage control resuscitation for patients with major trauma. BMJ 2009;338:b1778

Proven detrimental effects of aggressive fluid resuscitation

Hypothermia Independent predictor of mortality

Acidosis Higher mortality in critical care

Coagulopathy > 4x mortality

Measures as per <C>

Bind the pelvisSplint the femur(s)Damage control

surgery Interventional

radiology

Permissive hypotension + haemostatic resuscitation + damage control surgery

Permissive hypotension = “A strategy of deferring or restricting fluid administration until haemorrhage is controlled, while accepting a limited period of suboptimum end organ perfusion”

Haemostatic resuscitation = very early use of blood and blood products as primary resuscitation fluids

Jansen J et al. Damage control resuscitation for patients with major trauma. BMJ 2009;338:b1778

Should not be used in head injuriesMost applicable to penetrating

traumaOther terms

Hypotensive resuscitation Delayed resuscitation

Jansen J et al. Damage control resuscitation for patients with major trauma. BMJ 2009;338:b1778

Randomised 2 groups with penetrating trauma and BP <90 Immediate Delayed

BP >100 post anaesthesia

Bickell WH et al, NEJM 1994; 331:1105-9Bickell WH et al, NEJM 1994; 331:1105-9

Statistically significant findings: Survival higher in delayed group Stay shorter in delayed group

Trend towards Higher intra-op blood loss in the

immediate group ? More complications in immediate group

Not statistically significant

Bickell WH et al, NEJM 1994; 331:1105-9Bickell WH et al, NEJM 1994; 331:1105-9

Outcome of Patients with Penetrating Torso Injuries, According to Treatment Group

Coagulopathy causes• mortality• incidence of multi organ failure

• Renal • Acute lung injury

• ICU length of stay

Damage control resuscitation: Correct coagulopathy Limit duration of shock Reduce haemodilution

using high ratio blood component therapy Reduce hypothermia

Tranexamic acid Factor VIIa

role remains unproven

Each hospital should have oneSTH massive transfusion pack

4 units packed red cells 3 bags FFP 2 bags cryoprecipitate 1 adult dose platelets

Give empirically, with clotting studies

Holcomb J et al. Annals of Surgery 2008;248:477-458 Holcomb J et al. Annals of Surgery 2008;248:477-458

Increased Plasma and Platelet to Red Blood Cell Ratios Improves Outcome in 466 Massively Transfused Civilian Trauma Patients

Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients

Shaz BH et al. Transfusion 2010;50:493-500Shaz BH et al. Transfusion 2010;50:493-500

Over 20,000 patients ‘with or at risk of significant bleeding’

1g of tranexamic acid over 10 minutes followed by a further 1 g over 8 hours reduced all cause mortality and deaths due to bleeding

Further analysis showed that must be given within 3 hours of injury

Independant standard for achieving BPT

If the patient is to be intubated important to document beforehand: Level of consciousness

▪ Prognostically important Pupil size and reaction Lateralising signs e.g. weakness, sensory

loss Spinal cord injury level (if relevant)

A single episode of hypotension (systolic BP <80) doubles mortality

Aim for a higher BP to ensure an adequate cerebral perfusion pressure systolic >120mmHg, MAP >80

Concurrent penetrating trauma generates a difficult problem Balance need for hypotensive resuscitation

v. CPP BP target should be decided on a case by

case basis

Presume your patient is hypothermic or will develop hypothermia.A core temp of <35oc on

admission is an independent predictor of mortality

•Limit the exposure of the patient•Pre warm blood products and IV fluids•Forced air warming devices

• Systematic approach• Complete examination from head to toe

• “minor” injuries often missed• Complete history• Collect information

• bloods, x-rays, ECG etc• Formulate management plan• Document

• Who, what, when!

Initially perform only life saving procedures Stop the bleeding

Major surgery worsens the immune hit from trauma

Aim to stabilise and then resuscitate further on ICU Ex-fix not IM nail

Tschoeke SK, Ertel W Injury 2007;38:1346-57Tschoeke SK, Ertel W Injury 2007;38:1346-57

Consider in those with: ISS>40 Thoracic trauma Abdo/pelvic trauma Shock Head injury Pulmonary contusion Bilateral femoral fractures Temp<35

Gillian MJ, Parr MJA Current opinion in Anaesthesiology 2002;15:167-72 Gillian MJ, Parr MJA Current opinion in Anaesthesiology 2002;15:167-72

Pape HC et al. J Trauma 2002;53:452-62Pape HC et al. J Trauma 2002;53:452-62

Bose d, Tejwani NC. Injury 2006;37:20-28 Bose d, Tejwani NC. Injury 2006;37:20-28

Katsoulis E, Giannoudis PV. Injury 2006;37:1133-1142 Katsoulis E, Giannoudis PV. Injury 2006;37:1133-1142

EPOFF study group. Annals of Surgery 2007;246:491-499 EPOFF study group. Annals of Surgery 2007;246:491-499

EPOFF study group. Annals of Surgery 2007;246:491-499 EPOFF study group. Annals of Surgery 2007;246:491-499

EPOFF study group. Annals of Surgery 2007;246:491-499 EPOFF study group. Annals of Surgery 2007;246:491-499

Military practice has led to an evolution of modern trauma care

For exam purposes must know ATLS principles..

But....I think it’s **** for modern trauma care in a major trauma centre “officially endorsed”, but no other course

out there Key concepts

Haemorrhage control, tranexamic acid, DCR