trauma drama!
TRANSCRIPT
Trauma Drama!Stabilization of the critical trauma patient
Jacob A. Miller, ACNP, FNP, CNS, CCRN, CFRN, EMT-P, FP-C
Flight Nurse Practitioner & Clinical Nurse Specialist
Disclosures / Disclaimers
• No conflicts of interest or other disclosures.
• Any specific brands or products mentioned are illustrative and/or for clarity and not intended as product endorsement.
• This presentation is NOT a substitute for medical judgment or common sense. Contact medical control faculty as indicated.
Objectives
• Review evidence-based guidelines and literature support for initial assessment and resuscitation in the care of a trauma patient.
• Identify and discuss limitations and/or opportunities for improvement in the current EMS arena.
Preventable Deaths
J Surg Res 2016;200:604
Preventable Deaths
J Trauma Acute Care Surg 2017;82:S2
Curr Opin Hematol 2017;24:529
Ann Surg 2020;271:375
36%
13%30%
2020 Data:
Preventable Deaths
J Traum Acute Care Surg 2012;73:S431
Primary TRAUMA Survey
J Spec Oper Med 2011;11(3):104
J Spec Oper Med 2017;17(4):80
Primary TRAUMA Survey
assive hemorrhage irway
espiratory irculation
ead injuryypothermia J Spec Oper Med 2011;11:104
J Spec Oper Med 2017;17:80
Trauma Resuscitation
J Anaesthesiol Clin Pharmacol. 2015;31:308
Stop the Bleeding!
External hemorrhage:
• Tourniquet
• Hemostatic gauze
• Direct pressure
Air Med J 2019;38:209
BleedingControl.org
Pelvic Injuries
J Trauma 2019;24(5):379
Pelvic Injury
J Trauma 2009;66:815
Injury 2020;51:4
Stop the Bleeding!
• Sheets difficult to secure
– Higher incidence of lethal bleeding (23% vs 4-8%)*
• Pelvic binder > sheet
* Injury 2013;44:1760
Scand J Trauma Resusc Emerg Med 2016;24(1):110
Image: ATLS 10th Ed (2018)
Airway Management
Crit Care Horizons 2015;1:1
Ann Emerg Med 2016;68:181
Anesth Analg 2018;127:450
Emerg Med Clin N Am 2018;36:61
RSI with VL, DL, or FOB: 0/252 neuro deterioration
RSI + hypotension = bad!↓ induction dose↑ NMBA dose
Bougie & SALAD
Am J Emerg Med 2017;35:584
Rev Bras Anestesiol 2017;67:238
Emerg Med Clin N Am 2018;36:61
Air Med J 2019 (doi 10.1016/j.amj.2019.10.005)
Tension PTx
J Spec Oper Med 2018;18(4):19
Arch Surg 2012;147:813
J Spec Oper Med 2013;13(4):53
J Trauma Acute Care Surg 2012;73:1412
Oxygen
• Supplemental oxygen (empiric)
– Seems generally bad for everything
• High incidence of hyperoxia in trauma
– Hyper- and hypoxia might be bad in TBI
– Restrictive oxygen strategy may be feasible
• AVOID HYPOXIABMJ 2018;363:k4169
Lancet 2018;391(10131):1693-1705
Acta Anaesthesiol Scand 2019;63:531
Acta Anaesthesiol Scand 2019;63:947
Hemodynamic Support
J Anaesthesiol Clin Pharmacol. 2015;31:308
TIC: Lethal Triad
Emerg Nurse 2016;24(5):19
J Traum Acute Care Surg 2017;82:S33
TIC: Lethal Triad
Blood 2016;128:1043
J Traum Acute Care Surg 2017;82:S33
Fluid Resuscitation?
New Engl J Med 2018;378:829-39
J Anaesthesiol Clin Pharmacol 2015;31:308-16
J Vet Intern Med 2017;31:1371-81
Damage Control Resuscitation
Crit Care Clin 2017;33:15-36
Blood(?) for Blood
JAMA Surg 2013;148:127-36
JAMA 2015;313:471-82
Crit Care Clin 2017;33:15-36
Lancet 2018;392:283-91
New Engl J Med 2018;379:315-26
Ann Surg 2019 (doi 10.1097/SLA.0000000000003324)
• PROMMTT (2013)
• PROPPR (2015)
• COMBAT (2018)
• PAMPER (2018)
Blood(!) for Blood
New Engl J Med 2018;379:315-26
Ann Surg 2019 (doi 10.1097/SLA.0000000000003324)
PER LITER OF CRYSTALLOIDWITH BLOOD PRODUCTS
Hemodynamic Support
J Anaesthesiol Clin Pharmacol. 2015;31:308
Hemodynamic Support
World J Emerg Surg 2019;14:53
If LIFE THREATENING hemorrhage:
Beware Occult Badness
Shock Index Modified Shock Index
If >0.9: If >1.3 or <0.7↑ transfusion ↑ mortality
↑ mortality
↑ RSI arrest
J Trauma 2009;67:1426
J Trauma 2011;70:384
World J Emerg Med 2012;3:114
Crit Care 2013;17:R172
Resuscitation 2013;84:1500
(nl 0.5-0.7)
Beware Occult Badness
J Trauma 2009;67:1426
J Trauma 2011;70:384
World J Emerg Med 2012;3:114
Crit Care 2013;17:R172
Resuscitation 2013;84:1500
Coagulopathy Managment
J Anaesthesiol Clin Pharmacol. 2015;31:308
TIC: Lethal Triad
Injury 2013;44:86
Emerg Nurse 2016;24(5):19
Prehosp Emerg Care 2017;21:575
Prehosp Emerg Care 2020;24:15
Higher risk for hypothermia:- More severe injury / cormorbidities- Prehosp interventions, esp RSI
Possible TBI?
• Hypotension
• Hypoxia
• Hypoglycemia
• HyperventilationAnn Emerg Med 2017;69:62
JAMA Surg 2019;154:e191152
“H-Bombs”
Ann Emerg Med 2017;69:62
Increases in mortality risk
EPIC-TBI Bundle
• q3-5 minute HR/BP/SpO2
• 15 LPM oxygen NRB
• ANY SBP <90 mmHg:
– 1 liter crystalloid bolus, and
– IVF to keep SBP >90
• Vent rate timer on BVM; target EtCO2 40
– NO hyperventilation, even for “herniation”JAMA Surg 2019;154:e191152
EPIC-TBI results
JAMA Surg 2019;154:e191152
Relative increases in survival to discharge:
CRASH3 : TXA for TBI
Lancet 2019;394:1713
Summary / Recap
assive hemorrhage irway
espiratory irculation
ead injuryypothermia
Jacob A. Miller, ACNP, FNP, CNS, EMT-P
JacobMillerACNP.wordpress.com