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Advanced Trauma Life SupportAdvanced Trauma Life Support

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1. Preparation

2. Triage

3. Primary Survey (ABCDEs)

4. Resuscitation

5. Adjuncts to primary survey & resuscitation

6. Secondary Survey (head to toe evaluation & history)

7. Adjuncts to secondary survey

8. Continued post-resuscitation monitoring & re-evaluation

9. Definite care.

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1. PREPARATION1. PREPARATION

A Pre-hospital phase

Receiving hospital is notified first.

Send to the closest, appropriate facility.

B In Hospital Phase

Advanced planning for the trauma pt arrival.

Method to summon extra medical assistance

Transfer agreement with verified trauma center established.

Protect from communicable disease.

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2. TRIAGE2. TRIAGE

AA Multiple CasualtiesMultiple Casualties

no of severity & pt do not exceed the ability ofthe facility.

B Mass Casualties

no & severity of pt EXCEED the capability ofthe facility & staff.

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3. PRIMARY SURVEY3. PRIMARY SURVEY

A :A : Airway with cervical spine protect.

B :B : Breathing

C :C : Circulation --control external bleeding.

D :D : Disability or neurological status

E :E : Exposure (undress) & EEnvironment (temp control)

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PRIMARY SURVEY

Priorities for the care of Adult , Pediatrics& Pregnancy women are all the same.

During the primary survey life threateningconditions are identified and management isinstituted SIMULTANEOUSLY.

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A. Airway Maintenance with Cervical SpineA. Airway Maintenance with Cervical SpineProtection.Protection.

* GCS score of 8 or less require the placement of definiteairway.

*Protection of the spine & spinal cord is the importantmanagement principle.

*Neurological exam alone does not exclude a cervical spineinjury.

*Always assume a cervical spine injury in any pt with multi-system trauma, especially with an altered level of consciousnessor blunt injury above the clavicle.

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B. Breathing & VentilationB. Breathing & Ventilation

* Airway patency does not assure adequate ventilation.

C. Circulation with Hemorrhage Control.C. Circulation with Hemorrhage Control.

a. consciousness.

b. skin color

c. Pulse.

*external bleeding is identified & controlled in the

primary survey.

*Tourniquets should not be use.

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D. Disability ( Neurological Evaluation)D. Disability ( Neurological Evaluation)

Simple Mnemonic to describe level of consciousness

A : Alert

V : Responds to Vocal stimuli

P : Responds to Painful stimuli

U : Unresponsive to all stimuli

Not forget to use also Glascow Coma Scale.

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E. Exposure / Environmental ControlE. Exposure / Environmental Control

*It is the pt’s body temp that is most important, not hecomfort of the health care provider.

*Intravenous fluid should be warm.

*Warm environment (room tem) should be maintained.

*early control of hemorrhage.

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4. RESUSCITATION4. RESUSCITATION

A. Airway

*definite airway if there is any doubt about the pt’s ability tomaintain airway integrity.

B. Breathing /Ventilation/Oxygenation

*every injured pt should received supplement oxygen

C. Circulation

*control bleeding by direct pressure or operative intervention

* minimum of two large caliber IV should be established

*pregnancy test for all female of child bearing age.

* Lactated Ringer is preferred & better if warm.

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5.5. ADJUNCT TO PRIMARY SURVEY &ADJUNCT TO PRIMARY SURVEY &

RESUSCITATIONRESUSCITATION

A. Electro-cardiographic Monitoring

B. Urinary & Gastric Catheter

1. Urinary catheter.

Urethral injury should be suspected if

*Blood at the penile meatus

*Perineal ecchymosis

*Blood in the scrotum

*High riding or nonpalpable prostate

*Pelvic fracture

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C. Monitoring

1. Ventilatory rate & ABG

2. Pulse oximetry

does not measure ventilation or partial O2 pressure

3. Blood pressure

poor measure of actual tissue perfusion.

D. X-Ray & Diagnostic Studies

C-spine, CXR, Pelvic film

Essential x-ray should not be avoid in pregnant pt.

*** Consider the need for patient transfer.

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66 SECONDARY SURVEYSECONDARY SURVEY

Does not begin until the primary survey (ABCDEs)

is completed, resuscitative effort are well established

& the pt is demonstrating normalization of vital sign.

* Head to Toe evaluation & reassessment of all vital

signs.

* A complete neurological exam is performed including

a GCS score.

* Special procedure is order.

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History

A : Allergies.

M : Medication currently used.

P : Past illness/ Pregnancy.

L : Last Meal

E : Events/Environment related to the injury.

*blunt trauma/penetrating trauma/injuries dueto cold & burn/hazardous environment?

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PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

1. Head

Visual acuity

Pupillary size

Hemorrhage of conjunctiva and fundi

Penetrating injury

Contact lenses(remove before edema occurs)

Dislocation of lens

Ocular movement

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2. Maxillofacial Injury

no NG tube, definite airway?

3. Cervical Spine & Neck

*Pt with maxillofacial or head trauma should be presumedto have and unstable cervical spine.

4. Chest

*elderly pt are not tolerant of even relatively minorchest injury.

*Children often sustain significant injury to theintrathoracic structure without evidence of thoracicskeletal trauma.

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5. Abdomen

*excessive manipulation of the pelvic should be avoided.

6. Perineum/rectum/vagina

7. Musculoskeletal

8. Neurologic

* Protection of spinal cord is required at all times until aspine injury excluded, especially when the pt is transfer.

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7.7. ADJUNCT TO THE SECONDARY SURVEYADJUNCT TO THE SECONDARY SURVEY

include additional x-ray and all other special procedure.

8.8. RERE--EVALUATIONEVALUATION

Adult urine output 0.5ml/kg/hr

Pediatric urine output 1mg/kg/hr

*Pain relief -- IM should be avoid.

9. DEFINITE CARE9. DEFINITE CARE

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Indication For Definite Airway

* Unconscious

* Severe maxillo-facial fracture

* Risk for aspiration : Bleeding/ vomiting

* Risk for obstruction : neck hematoma/laryngeal,trachealinjury/ stridor

* Apnea : Neuromuscular paralysis/unconscious

* Inadequate respiratory effort:tachypnea/hypoxia/hypercapnia/cyanosis

* Severe closed head injury need for hyperventilation

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Normal Blood Amount:Normal Blood Amount:

Normal adult blood volume : 7% of body weight

Normal blood volume for child : 8-9% of body weight

Hemorrhage Classification :Hemorrhage Classification :

Class I Hemorrhage : up to 15% loss

Class II Hemorrhage : 15-30% loss

Class III Hemorrhage : 30-40% loss

Class IV Hemorrhage : >40% loss

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33 for 1 Rulefor 1 Rule

a rough guideline for the total amount ofcrystalloid volume acutely is to replace eachML of blood loss with 3 ML of crystalloidfluid, thus allowing for restitution of plasmavolume lost into the interstitial &intracellular space

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Initial Fluid TherapyInitial Fluid Therapy

Normal Saline is preferredNormal Saline is preferred

* For adult 1-2 liters bolus

* For child 20ml/kg bolus

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Intraosseous Puncture/InfusionIntraosseous Puncture/Infusion

Children less than 6 y/o for IV access isimpossible due to circulatory collapse or

for whom percutaneous peripheral venouscannulation had failed on two attempt.

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Head Injury Classification:

Mild : GCS 14-15

Moderate : GCS 9-13

Severe : GCS 3-8

Coma = GCS score of 8 or less

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Diagnostic Peritoneal Lavage Indication

A. Change in sensorium--Head injury/alcohol/drug.

B. Change in sensation--Spinal cord injury.

C. Injury to adjacent structure--lower

ribs/pelvic/lumbar spine.

D. Equivocal physical examination.

E. Prolong loss of contact with patient anticipated.

*** Positive Test: >100,000 RBC/mm3, >500 WBC/mm3or Gram Stain with bacteria

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Determining the level of quadriplegia

a. Raise elbow to level of shoulder -- Deltoid C5

b. Flexes the forearm -- Biceps C6

c. Extend the forearm -- Triceps C7

d. Flexes wrist & finger -- C8

e. Spread fingers -- T1

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Determine the level of paraplegia

a. Flexes the hip -- Iliopsoas L2

b. Extend knee -- Quadriceps L3

c. Dorsiflexes ankle -- Tibialis anterior L4

d. Plantar flexes ankle -- Gastrocnemius S1

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Thoracic Trauma

8 lethal Injuries

1. Simple pneumothorax

2. Hemothorax

3. Pulmonary contusion

4. Tracheo-bronchial tree injury

5. Blunt cardiac injury

6. Traumatic aortic disruption

7. Traumatic diaphragmatic injury

8. Mediastinal traversing wounds.

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Fluid Therapy in2nd or 3rd Degree Burn

(parkland formula)

Total amount of first 24 hours:

4 ml of Ringer lactate x BW(kg) x BSA

* give 1/2 in first 8 hrs

* 1/2 in remaining 16 hrs

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Referral to Burn Center

* 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y/o

* 2nd or 3rd degree burn > 20% BSA in other age group

* 2nd or 3rd degree burn of face/eye/ear/hands/feet/genitalia/perineum or major joints

* 3rd degree burn >5% in any age group

* Significant electrical/lightning injury

* Significant chemical burn

* Inhalation injury

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Color Codes Triage TagColor Codes Triage Tag

RED : Most critical injury

YELLOW : Less critical injured

GREEN : No life or limb threatened injury

BLACK : Death or obviously fatal injury

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Priorities with multiple injuriesPriorities with multiple injuries

1. Thoracic trauma or tamponade

2. Abdominal hemorrhage

3. Pelvic Hemorrhage

4. Extremity Hemorrhage

5. Intra-cranial Injury

6. Acute Spinal Cord Injury

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TRAUMA & MULTIPLE INJURY

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INJURY BIOMECHANICS ANDACCIDENT PREVENTION

• The magnitude of an injury is related to energytransferred to the victim during the event, thevolume/area of tissue involved and the timetaken for the interaction

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ALCOHOL & DRUGS

• TRAUMA DUE TO ALCOHOL IN ASSAULTS – 60%

BURNS

HOMICIDES

DROWNING

ROAD TRAFFIC ACCIDENT – 10%

• DEATH DUE TO ALCOHOL IN RTA- 1/3 OF DEATH (30%)

• DEATH DUE TO ALCOHOL IN RTA- 20%

30% - 50%

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WOUNDS

CLASSIFICATION

• ABRASION OR GRAZES

• CONTUSIONS , ECCHYMOSES OR BRUISES

• LACERATIONS

• INCISED WOUNDS / CUTS

• PUNCTURE WOUNDS

• GUNSHOT WOUNDS

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FALLS

• Major determinant of injury and the chance ofdeath is directly proportional to the height fallen.

• At impact the decelerating forces aredetermined by the individual’s mass , the natureof the landing surface and the body’s orientationon landing

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INJURY SEVERITY ASSESSMENT

• Abbreviated Injury Scale (A.I.S) – Severity ofAnatomical injury

• Glasgow Coma Scale (G.C.S) – Assess theneurological state of mind

• GCS + Systolic B.P + Respiratory rate -----Revised Trauma Score

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GCS

• Eye opening– Spontaneously 4– to speech 3– to pain 2– none 1

•• Verbal Response

– Orientated 5– Confused 4– inappropriate words 3– incomprehensible sounds 2– none 1

• Motor Response– Obey commands 6– Localizes to pain 5– Flexion(withdraw)to pain 4– Abnormal flexion to pain 3– Extension to pain 2– None 1

• - Total /15

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ASSESSING MUSCLE POWER- theMRC scale

• No flicker movement 0

• A flicker of contraction,but no movement 1

• Movement, with gravity neutralized 2

• Movement against gravity 3

• Movement against added resistance 4

• Normal power 5

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IMAGING & OTHER DIAGNOSTICAIDS

• INITIAL X RAYS

CHEST

CERVICAL SPINE

PELVIS

THORACIC / LUMBAR VIEWS

• FOR HEAD,SPINAL AND PELVIC INJURY -

CT SCAN

SKULL X RAY

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AFTER THE RESUSCITATION ROOM

• Immediate aim of resuscitation is to assess & treat life threatening injuries• Patient with Patent Airways• Adequate Gas Exchange• Circulatory Status is normal• Long Bone Fractures Splinted• Cervical Spine Control maintained throughout• Identify the correct destination for the patient• Perform Surgical Intervention if needed• Full Monitoring & Resuscitation Equipment mandatory if to be transferred to

theatre• If to be transferred to another Hospital should be done appropriately• Regular updates should be supplied to the receiving specialists.

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PREHOSPITAL CARE & TRANSPORT

• AMBULANCE SERVICES (land based vehicles,Helicopters , fixed wing air craft)

• PARAMEDICS

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RESUSCITATION IN THE A&EDEPARTMENT

FIRST 10 MINUTES• -------------------------• AIRWAY• CONTROL OF CERVICAL SPINE• ADVANCED AIRWAY TECHNIQUES• BREATHING• CIRCULATION• ANALGESIA & SPLINTING

NEXT PHASE• ------------------• PATIENT EXAMINED FROM TOP TO TOE• BACK & SPINE ARE EXAMINED• LOOKING FOR LOCALISED TENDERNESS/SWELLING / OR A ‘STEP’• PERINEUM IS EXAMINED• RECTAL EXAMINATION IS PERFORMED• NEUROLOGICAL EXAMINATION• EXAMINE FOR EVIDENCE OF SKULL BASE INJURY• MUSCLE POWER TESTED USING MRC SCALE• TENDON REFLEXES EXAMINED

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Abdominal trauma

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Overview

• Epidemiology

• Anatomy

• Initial Evaluation

• Blunt Abdominal Trauma

• Penetrating Abdominal Trauma

• Pediatric Abdominal Trauma

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Epidemiology

• Blunt Abdominal Trauma

– Blunt Abdominal Trauma = 66-75%

• MVA leading cause

• Penetrating Abdominal Trauma

– 30,708 deaths due to GSW in USA during ’00

– USA firearm deaths far exceeds all Europeancountries

• Norway has highest European firearm death rate (1/5 ofUSA)

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Epidemiology

• Mortality

– 6-10% of all patients w/ Abdominal Trauma

• However polytrauma may skew this figure

– ~50% of all OR deaths 1° due to ABD Trauma

• Age

– Peak 14-30 y/o

• Gender

– 60:40 Males

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Overview

• Epidemiology

• Anatomy

• Initial Evaluation

• Blunt Abdominal Trauma (BAT)

• Penetrating Abdominal Trauma

• Pediatric Abdominal Trauma

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Anatomy

• Peritoneal Cavity

– Upper Half

• Diaphragm– Expiration = Diaphragm rises to 4th intercostal space

– Places intra-abdominal contents at risk from rib fracture

• Liver & Spleen

• Stomach & Transverse Colon

– Lower Half

• Small Bowel

• Sigmoid Colon

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Anatomy

• Pelvic Cavity

– Protected by pelvic bones

• Bladder, Rectum, Large Blood Vessels, +/- Uterus– Also at increased risk from pelvic fracture (esp. bladder)

• Retroperitoneal Space

– Tough to determine/examine but not to forget

• Abdomial Aorta, IVC, Duodenum, Pancreas, Kidneys,Ascending/Descending Colon.

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Overview

• Epidemiology

• Anatomy

• Initial Evaluation

• Blunt Abdominal Trauma

• Penetrating Abdominal Trauma

• Pediatric Abdominal Trauma

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Initial Evaluation

• History• Unless ABC & Resuscitation required immediately

– AMPLE history

• A – Allergy

• M – Medications

• P – Past Medical History

• L – Last PO Intake

• E – Events leading to presentation

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Initial Evaluation

• Pertinent History

– MVA

• Belted

• Air Bag Deployment

• Patient’s Position in Vehicle

• Speed

• Type of Collision ( frontal, side, rear )

• Status of other Passengers

– Fall

• Height

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Initial Evaluation

• Pertinent History

– Penetrating

• Time

• Type of Weapon (knife, handgun, shotgun, uzi)

• Length of knife

• Number of stab wounds & number shots fired

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Initial Evaluation

• Physical Exam

– Inspection

• Fully Expose Patient

• Abrasions & Contusions from restraint devices– Seat Belt sign (ABD or Chest)

• Find source for Bleeding– Lacerations

– Impaled Foreign Bodies

– Penetrating Wounds

• Identify the “Pregnant Abdomen”

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Initial Evaluation

• Physical Exam

– Auscultation

• Confirm presence of bowel sounds– Free intraperitoneal air, blood, bowel contents = Ileus

– However, injuries to adjacent structures may cause ileus

» Ribs, pelvis, spine

– Percussion

• Pain with slight mov’t of ABD wall = peritonitis

• Tympanic Sound = Free Air

• Dull Sound = Hemoperitoneum

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Initial Evaluation

• Physical Exam

– Palpation

• Guarding = involuntary muscle contraction– Sign of peritoneal irritation

• Rebound Tenderness = Pain after rapid removal– Indicates established peritonitis from blood / GI contents

• Gravid Uterus– Fundus @ Umbilicus = 20 week Gestation

» Viable Fetus (in theory)

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Initial Evaluation

• Physical Exam

– Penetrating Wounds

• Do not explore

• Apply pressure to control bleeding

– Impaled Objects

• Do not remove

• Stabilized object and transport

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Initial Evaluation

• Physical Exam

– Pelvic Stability

• Compression of Iliac Crests– Mov’t or Bony Pain = Possible Fracture

– Perineum

• Blood @ Penile Meatus = Urethral Tear

• Scrotal Hematoma = Pelvic Fracture

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Overview

• Epidemiology

• Anatomy

• Initial Evaluation

• Blunt Abdominal Trauma

• Penetrating Abdominal Trauma

• Pediatric Abdominal Trauma

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Blunt Abdominal Trauma

• Most Commonly Injured Organs

1. Spleen

2. Liver

3. Small Intestine

4. Large Intestine

• Two Primary Mechanisms

– Compression

– Deceleration

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Blunt Abdominal Trauma

• Compression Injury

– Result from direct blows or external compressionagainst a fixed object (lap belt, spinal column).

– Subcapsular Hematomas to Solid Organs

• Caused by small tears

• Most common injury

– Hollow Organ Rupture

• Transient pressure ↑ = Intraluminal Pressure ↑ = Rupture

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Blunt Abdominal Trauma

• Deceleration Injury

– Result from a differential movement of fixed andnon-fixed parts of the body.

– Tears occur @ Junction of Support Structures

• Ligamentum Teres = Liver Laceration

• Mesentery of Bowel = Mesenteric Tear

• Retroperitoneum = Renal Artery Laceration

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Blunt Abdominal Trauma

• Pre-Hospital Management

– ABC’s

– IV Access

• 2 Large Bore peripheral IV (if possible)

• Never delay transport for IV Access

– IVF Crystalloid Resuscitation

• Titrate Volume to Patient’s Clinical Response (VS)

• Goal BP Mgt = SBP 90-100

• Be Wary of Over Resuscitation = Hemodilution

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Blunt Abdominal Trauma

• Pre-Hospital Management

– Prolonged Transport Times & Hypotension

• May be role for Pneumatic Anti-Shock Garments

• Especially in case of Pelvic Fracture & Shock

• Remember…More fluids may not be the answer– These Patients need definitive treatment at a Hospital

» STOP THE BLEEDING

» FILL THE TANK…with BLOOD

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Blunt Abdominal Trauma

• Emergency Department Management

– Initial Stabilization

• Definitive Vascular Access– Central Lines

• Continued Fluid Resuscitation– Crystalloid

– Colloid (pRBCs)

» Important here for EMS notification – ED order O neg

• Lucky Us!! → Rectal Exam

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Blunt Abdominal Trauma

• Emergency Department Management

– Decision Tree

Unstable Pt. Positive FAST Neg. FAST

+ Hypotension Stable

OR OR CT A/P

Observe

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Overview

• Epidemiology

• Anatomy

• Initial Evaluation

• Blunt Abdominal Trauma

• Penetrating Abdominal Trauma

• Pediatric Abdominal Trauma

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Penetrating Abdominal Trauma

• Major Offenders

– GSW

– Stab Wounds

– High mortality rate associated with abdominal GSW& Stab due to Hemorrhage & Shock

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Penetrating Abdominal Trauma

• Most Common HPI:

I was minding my own business when…

“Some Dude”

“Two Dudes”

“That *!#@!”

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Shock Classification

• Class I Hemorrhage (loss of 0-15%)

– Minimal Tachycardia

– No BP change

• Class II Hemorrhage (loss of 15-30%)

– Tachycardia

– Delayed cap refill

– Cool clammy skin

– Anxiety

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Shock Classification

• Class III Hemorrhage (loss of 30-40%)

– Marked Tachycardia

– Marked Tachypnea

– Hypotension

– Change Mental Status

– Agitation &/or Anxiety

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Shock Classification

• Class IV Hemorrahge (loss of >40%)

– Marked Tachycardia

– Marked Tachypnea

– Hypotension

– Narrow Pulse Pressure

• Or immeasurable diastolic BP

– Cold/Pale skin

– Change in MS or Unconscious

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Shock Classification

• Caveat:

– Compensatory mechanisms prevent Hypotension

• So look for Tachycardia

– Patients on B-blockers will not be Tachycardic!!

– Elderly patients may not Compensate well

• ie. HR

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Penetrating Abdominal Trauma

• GSW

– Missile with high-energy transfer

– Unpredictable extent of intra-abdominal injury

• Missile track

• Secondary missiles– Bullet fragments

– Bone fragments

• Stab Wounds

– More predictable regarding injured organs

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Penetrating Abdominal Trauma

• Pre-Hospital Management

– ABC’s

– IV Access

• 2 Large Bore peripheral IV (if possible)

• Never delay transport for IV Access

– IVF Crystalloid Resuscitation

• Titrate Volume to Patient’s Clinical Response (VS)

• Goal BP Mgt = SBP 90-100

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Penetrating Abdominal Trauma

• Pre-Hospital Management

– Do not remove impaled objects or probe wounds

– Patients should be delivered to Level I or next bestfacility

– As always, unstable patients should go to closest ED

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Wound Ballistics

• Wound Ballistics

– A very mystifying and often factitious specialty

– Often entangles terms such as “projectile-tissueinteractions” and “stopping power”

– Tough field to study, because not many people arevolunteering to be shot in the name of “science”

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Wound Ballistics

• Simplest Convention(for me)

“Bullet Velocity”

Velocity to:

Penetrate Skin = 163 fps

Break Bone = 213 fps

** Other factors are important**

Popular Weaponry

9mm = 1155 fps

.357 magnum = 1450 fps

AK-47 = 2400 fps

M-16 = 3100 fps

Belkin, 1978

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Overview

• Epidemiology

• Anatomy

• Initial Evaluation

• Blunt Abdominal Trauma

• Penetrating Abdominal Trauma

• Pediatric Abdominal Trauma

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Pediatric Abdominal Trauma

• Epidemiology

– Trauma is leading cause of Morbidity & Mortality inpediatric population

– Abdominal Trauma associated with 8.5% Mortalityrate

– 8-10% of all Trauma admissions in children

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Pediatric Abdominal Trauma

• Pathophysiology

– Unique Anatomy to Pediatric Patients

• Thinner musculature & padding = less protection

• Ribs are more flexible = less dissipation of energy

• Solid organs are comparatively larger than adult

• Kidney more mobile = more commonly injured

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Pediatric Abdominal Trauma

• Frequency of Organ InjuryBlunt Penetrating

Liver 15% 22%

Spleen 27% 9%

Pancreas 2% 6%

Kidney 27% 9%

Stomach 1% 10%

Duodenum 3% 4%

Small bowel 6% 18%

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Pediatric Abdominal Trauma

• Duodenal Hematoma

– Classic Case:

• Kid falls off bike and strikes abdomen on end ofhandlebar…complaining continuing pain after

– Duodenum

• Located in mid-epigastric reagion

• Fixed portion of bowel to retroperitoneum

– Medical Issue

• Hematoma can cause obstruction

• Worst case = Hematoma leads to bowl wall necrosis

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Pediatric Abdominal Trauma

• Spleen Rupture

– Commonly Seen:

• Blunt Trauma to LUQ/Flank

• Football Players, Snowboarder/Skier

– Why so High Risk?

• Anatomic Position (with ribs overlaying)

• Thin Capsule

• Predisposition– Mononucleosis, Malaria, etc. lead to Splenomegaly

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Pediatric Abdominal Trauma

• Spleen Rupture

– Exam

• Pain in LUQ

• Left Shoulder Pain “Kehr’s Sign” – referred pain

• Peritoneal Abdomen

• Shock

– Management

• Fluid Resuscitation

• OR vs. Embolization

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Pediatric Abdominal Trauma

• Child Abuse

– Occurs in All Socioeconomic Groups

– Equal Gender Prevalence

– Can occur at any age

– The key is to have a high level of suspicion

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Pediatric Abdominal Trauma

• Child Abuse

– Non-accidental Trauma

• Burn marks without splash marks

• Wounds in various stages of healing

• Whip marks

• Suspicious Bruising

– What to do?

• Protect the Child

• Do not allow an RMA

• Alert RN / Physician staff of suspicion

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Presentation prepared basing onfollowing presentation:

•• Advanced Trauma Life SupportAdvanced Trauma Life Support ReviewReview By Don Hudson, D.O.,FACEP/ACOEP Emergency Medicine Department AlaskaRegional Hospital

• Abdominal Trauma by Brett Wiesley, MD

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Transfusion And ResuscitationGuidelines

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Transfusion guidelines:

• State goals for fluid replacement

• Define conditions when blood and bloodproducts are appropriate

• Must be followed unless the clinical situationjustifies deviations

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Blood products include:

Red blood cells:

• Blood bank

• Autologous (cell saver)

• Whole blood

• Fresh frozen plasma

• Platelets

• Fibrinogen concentrate/cryoprecipitate

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Managing Blood Loss ThroughTransfusion

Always ask:

• Is fluid resuscitation indicated?

• Is the patient hemodynamically stable?

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Fluid Resuscitation Goals

Within the first 24 hours, fluids must be provided untilacidosisis under control:

• Lactate <2.5 mmol/L or

• Base deficit <2

Targets for blood tests:

• Hemoglobin >8 and <10 g/dL

• INR <1.5, PT <16 seconds, APTT <30 seconds

• Fibrinogen >1 g/L

• Platelets >50 x 109/L

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Hemodynamic Stability:The 90 mmHg Cutoff

Patients are hemodynamically unstable if

• SBP <90 mmHg or

• Maintaining SBP >90 mmHg requires massivefluids or vasopressor support

Patients are hemodynamically stable if

• SBP >90 mmHg for 1 hour without thesemeasures

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RBC Use

Hypoperfusion indicators

• Continued slow bleeding

• Hgb

• Urine Output

• HR >120 w/ adequate analgesia

• CI <3L/m2 + PCWP or CVP

• SaO2 due to acute lung injury or altitude

• Coronary or other organ ischemia syndromes

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Damage control

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The concept of „damage control“

• Aims At rapid control Of hemorrhageAppears to reduce patient mortality Limitsvariability in RBC use Over first 24 Hours

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Damage Control: Staged SurgicalRepair

Stages of damage control:

• Phase 1: Rapid transport, warming, bleeding control

• Phase 2: Surgical control of hemorrhage andcontamination: pack and close temporarily

• Phase 3: Resuscitation and stabilization

• Phase 4: Definitive surgical repair

The goal is to achieve immediate control of life-threatening hemorrhage, avoiding patient deaththrough exsanguination

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Physiologic Exhaustion

• Low Core Temperature

• Increased Base Deficit

• Coagulopathy

• Bowel Edema

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Goals Of Secondary Resuscitation

• Correction of hypothermia (warm room, insulation,internal or external active warming)

• Correct Coagulopathy

• Correct Acidosis and Optimize Hemodynamics

• Ventilate

• Assess for Missed Injuries

• Identify Patients who may benefit from Surgical Re-exploration

• Initiating Specific Therapy to Reduce Complications

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Endpoints Of Secondary Resuscitation

Parameter Goal :

• SvO2 > 65%

• SaO2 > 95%

• DO2I > 550 ml/min/m2

• CI > 2,5-3 L/min

• EDVI 80-120 ml/m2

• Hct > 30-35%

• Lactate < 2.5mg

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Reconstruction And Closure

Single Stage

Multiple Stage

• Life

• Neurosurgical Decompression

• Failure of Hemorrhage Control

• Function

• Orthopedics

• Cosmetic

• Facial Fractures

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Strategies To Reduce Complications

• Measurement of Intra Abdominal Pressure >30mmHg confirms abdominal compartmentsyndrome

• Peptic Ulceration Prophylaxis

• Thromboprophylaxis

• Protective Lung Ventilation

• Infection Control

• Early Nutritional Support

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Ventilator Protocol andLung Protection Strategy

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Respiratory problems

SIGNS OF INTOLERANCE: Any of the following:

• SaO2 ≤90% or PaO2 <60 mmHg at oxygensupplementation

• Respiratory rate >35 breaths per minute

• Respiratory distress (defined as marked use ofaccessory muscles or paradoxical breathing)

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Respiratory Distress vs. Respiratory FailureRespiratory Distress vs. Respiratory Failure

DistressDistress

--Increased work of breathingIncreased work of breathing

--RelativeRelative hypoxia/hypoxia/hypercapneahypercapnea

--CompensatingCompensating

FailureFailure

--Increased work of breathingIncreased work of breathing

--ProfoundProfound hypoxia/hypoxia/hypercapneahypercapnea

--DecompensatingDecompensating -- leading toleading torespiratory arrestrespiratory arrest

It’s a constant reassessment process…

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Goals Of Ventilator Management AndWeaning Guidelines

1. Ensure low tidal volumes (Vt) are used:

• Limiting ventilation volumes (Vt) to 6 ±2 mL/kg PBW

2. Provide a lung-protective strategy for all ventilated patients:

• Limiting plateau airway pressures to ≤30 cm H2O wheneverpossible

3. Provide guidelines for the use of positive end-expiratorypressure (PEEP):

• Decreasing PEEP and FiO2 as early as possible givenoxygenation guidelines to move to spontaneous breathing trial(SBT) as soonas possible

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Goals Of Ventilator Management AndWeaning Guidelines

4. Ensure extubation or discontinuation ofmechanical ventilation at earliest possible time:

• Attempting to wean on an ongoing basis, atleast once daily when weaning criteria met

5. Avoid the use of muscle relaxants, exceptwhere specifically indicated.

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Predicted Body Weight

PBW calculated as follows:

• For males: PBW (kg) = 50 + .91 [height (cm) –152.4]

• For females: PBW (kg) = 45.5 + .91 [height (cm)– 152.4]

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Initiating Ventilator Procedures:

Oxygenation goal:

• PaO2 55–80 mmHg or

• SpO2 88–95%

PEEP:

• Must be <35 cm H2O

• Percent O2/PEEP ratio should be = 5±1

Example: FiO2 0.50; PEEP 12 (50/12 = 4.1)

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Continuing Ventilator Management:pH Guidelines

Adjust for pH goal 7.25–7.45 (if possible):

• Use resp rate (RR) if possible (≤35/min):

• Keep PaCO2 ≥25 mmHg

• Bicarb infusion can be given at discretion ofbedside physician

• If pH ≤7.15, then Vt can be increased by 1mL/kg to achieve pH >7.15, and target plateaupressure (Pplat) may be exceeded

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Presentation prepared basing onpresentations:

• Dr Gordon Bernard Professor Medicine,Allergy/Pulmonary and Critical Care, MedicineVanderbilt University School of Medicine

• Dr Michael Parr, Intensive Care Unit, LiverpoolHospital, Sydney, Australia

• Dr John A. Morris Jr Professor of Surgery VanderbiltCoordinating Center, Nashville, Tennessee, USA

• Professor Bertil Bouillon Campus Cologne Merheim,University Witten/Herdecke, Germany

Novo Nordisk Control Clinical Trial materials