perioperative complications of trauma (near) misses case discussions linda e. pelinka, m.d., ph.d....
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PERIOPERATIVE COMPLICATIONS OF TRAUMA
(Near) MissesCase Discussions
Linda E. Pelinka, M.D., Ph.D.Medical University of Viennaand Ludwig Boltzmann Institute
for Experimental & Clinical TraumatologyVienna, Austria, European Union
TRAUMA
……while it is while it is
critically important to learn critically important to learn
the skills of intubation, the skills of intubation,
knowing the sequence knowing the sequence
and tasks alone and tasks alone
does not guarantee successdoes not guarantee success. .
IS THE TUBE IS THE TUBE WHERE IT SHOULD BE?WHERE IT SHOULD BE?
Visualization of ETT passing through cordsVisualization of ETT passing through cords
Auscultation of breath soundsAuscultation of breath sounds
Condensation inside the ETT Condensation inside the ETT
Symmetric chest rise/fall with ventilationSymmetric chest rise/fall with ventilation
Absence of sounds over epigastriumAbsence of sounds over epigastrium
Have all been shown to be Have all been shown to be unreliable unreliable
in the in the hospitalhospital setting setting
Swanson ER et al. Air Medical Journal 2005; 24/1: 40-6.Swanson ER et al. Air Medical Journal 2005; 24/1: 40-6.
Are likely to be even less reliable Are likely to be even less reliable
in the in the prehospitalprehospital setting setting
PULSE OXIMETRY – PULSE OXIMETRY – ININDIRECT techniqueDIRECT technique
is reliable for oxygenation, is reliable for oxygenation,
but measures oxygenation but measures oxygenation
inindirectly.directly.
Green SM, Krauss B, Academic Emerg Med 2002; 9: 35-42.Green SM, Krauss B, Academic Emerg Med 2002; 9: 35-42.
MONITORINGMONITORING
CAPNOGRAPHYCAPNOGRAPHY – – DIRECT technique DIRECT technique
detects detects
breathing abnormalities directly and breathing abnormalities directly and
almost immediatelyalmost immediately
apnea: loss of COapnea: loss of CO22 wave. wave.
AMERICAN POINT OF VIEW:
Patient unconscious and full stomach,
INTUBATION MANDATORY to avoid
danger of vomiting & aspiration, however:
RSI
MONITORING MANDATORY
EUROPEAN POINT OF VIEW:Patient unconscious, however:Breathing spontaneouslySufficient O2sat considering asthmaFull stomachHospital 15 min awayWHY INTUBATE? RISK OF INTUBATION vs. RISK OF ASPIRATION
Outcomes after out-of-hospital endotracheal intubation errors
Results: of 1954 out-of-hospital ETI, 444 patients (22.7%) experienced one or more ETI errors:Failed ETI in 359 (15%) Multiple ETI attempts in 62 (3%) Tube misplacement or dislodgement
in 61 (3%)
,
Wang HE et al, Resuscitation 2009; 80/1: 50-55.
Emergency ventilatory management in hemorrhagic states:
elemental or detrimental?
Early intubation of polytrauma
is associated with increased mortality.
Evidence supports the scoop and run approach.
Pepe P et al. J Trauma 2003;54:1048-55.
Safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury.
Airway management should avoid producing
or worsening neurological deficits secondary
to movements of the c-spine.
Presence of a foreign body in the spinal canal
increases the risk.
Shatney CH et al. Am J Surg 1995; 170: 676-80.
Endotracheal intubation in the field improves survival in patients
with severe head injury.
Prehospital intubation was found to
improve survival significantly in
TBI patients with GCS 8 or less.
Survival increased from 64% to 74%.
Winchell RJ, Hoyt DB: Arch Surg 1997; 132: 592-7.
Prehospital airway managementfor severe brain injury
Prehospital airway management in TBI
is receiving critical review.
There are a growing number of reports suggesting
an association
between early intubation and increased mortality.
Parr M. Resuscitation 2008: 76, 321-322
Prehospital airway managementfor severe brain injury
It is well recognized that hypoxaemia and
hypotension are common in the prehospital phase
of TBI and have a significant impact on outcome.
It would therefore appear to be
logical to advocate prehospital RSI & intubation
for patients with severe TBI.
We need definitive studies.
Parr M. Resuscitation 2008: 76, 321-322
PREHOSPITAL PREHOSPITAL INTUBATION INTUBATION
of SEVERE TBI? of SEVERE TBI?
trauma.org 2007
GOAL: MINIMIZE SECONDARY BRAIN DAMAGE
HYPOXIA
HYPOTENSION
Chesnut R, New Horizons 2000
SECONDARY BRAIN DAMAGE
DOUBLEDOUBLE
MORTALITYMORTALITY
AFTER AFTER
TBITBI
Trauma in the prehospital setting:
QUESTION #1
Is an airway necessary right away or can it wait until the hospital?
Trauma in the prehospital setting:
QUESTION #2
If an airway is necessary, is there any additional
(airway) difficulty?
Main problems
blood loss and shock
Scoop &run w/o intubation (Europe):
GET TO SURGERY ASAP
Hemo-pneumothorax:
NO INTUBATION
W/O CHEST DRAINRISK OF INTUBATION vs. RISK OF ASPIRATION
In the head-injured,
unresponsive patient:
CT is the diagnostic
METHOD OF CHOICE:
from a medical point of view
from a legal point of view
from an ethical point of view
Survival of trauma patients who have prehospital
tracheal intubation without anaesthesia or muscle relaxants
If patients are so deeply comatose that they do not
require any anaesthesia or muscle relaxant for
intubation, prognosis is largely hopeless. In an observational study of 486 patients
intubated prehospital without anaesthetic drugs,
only 1 patient survived to hospital
discharge.
Lockey D, et al. Br Med J 2001;323:141.
Two things are infinite –the universe
and human stupidity…
Albert Einstein
...and I’m not sure about the universe.
Use of Recombinant Activated Factor VIIa to Treat the Acquired Coagulopathy of Trauma
Conclusion: Animal studies: stronger clot formation.Clinical study: decreased blood loss, decreased
transfusions, no increased thrombotic complications.Potential usefulness of rFVIIa in patients with
acquired coagulopathies from both blunt and penetrating trauma, efficacy of aFVIIa in reversing coagulopathy of trauma
JB Holcomb, J Trauma 58: 1298-1303; 2005.
Decreased transfusion utilization and improved outcome associated with use
of rFVIIa as an adjunct in trauma.
Multicenter, prospective, double-blind RCT trial of efficacy and safety of recombinant factor VIIa as adjunctive therapy in trauma.
32 centers, 8 countries, 277 pts (50% blunt/50% pen)First dose of rFVIIa following 8th unit of PRC, add.
doses 1 & 3 hrs later (200+100+100 ug/kg)
D Boffard, B Warren, J Trauma 57: 451; 2004.
1 of 2
Findings:Decreased transfusions in penetrating trauma, but
not statistically significant Statistically significantly decreased
transfusions in blunt trauma.No safety issues, no thromboembolic events.
2 of 2
Decreased transfusion utilization and improved outcome associated with use
of rFVIIa as an adjunct in trauma.D Boffard, B Warren, J Trauma 57: 451; 2004.
ADRENERGIC AGENTS ICU vs OR
DRUG DOSE MIMETIC
NOREPINEPHRINE0.04-0.4
µg/kg/mindirect
90% Alpha
DOBUTAMINE 2-20 µg/kg/mindirect
90% Beta
EPINEPHRINE 100-200 µg/kgindirect
Alpha & Beta
Anesthetic Management of a Patient in Prone Position with
a Drill Bit Penetrating the Spinal Canal at C1-C2, using
a Laryngeal Mask
Valero R et al. Anesth Analg 2004; 98:1447-50.
AMERICAN POINT OF VIEW:Patient unconscious and full stomach,
INTUBATION MANDATORY to avoid danger of vomiting &
aspiration, however :RSIMONITORING MANDATORY
EUROPEAN POINT OF VIEW:Patient unconscious, however:Full stomachHospital close bySufficient O2sat
Risk of intubation vs. Risk of aspiration
In the head-injured,
unresponsive patient:
CT is the diagnostic
METHOD OF CHOICE:
from a medical point of view
from a legal point of view
from an ethical point of view