what is the point of this talk? › uploads › sites › 2 › 2017 › 02 › trauma_… · what...
TRANSCRIPT
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WHAT IS THE POINT OF THIS TALK?
•1 HOUR OF CPD
•TAKE THE TRAUMA OUT OF TRAUMA
•IMPROVE OUR UNDERSTANDING OF TRAUMA SO WE CAN
PROVIDE BETTER CARE
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WHAT IS TRAUMA?
TRAUMA = TISSUE INJURY
• Blunt trauma- RTA, kick, hit with
object
• Penetrating trauma- gunshot
wounds, stab wounds, bite wounds
• Environmental trauma- burns,
electrocution, frostbite
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WHAT DO WE KNOW?
•TRAUMA >10% OF VET HOSP ADMISSIONS
•INVOLVES SERIOUS INJURIES IN APPROX. 35% OF CASES
•MORTALITY RATES APPROX. 10% IN DOGS
Ref: JVECC (2014) 24:1 pp 93-104
TRAUMA IMPACTS MANY LIVES!
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WHAT ELSE DO WE KNOW?•UPTO 43% IN DOGS WITH BLUNT TRAUMA HAVE HAEMOABDOMEN
•INTRODUCTION OF FAST HAS INCREASED THE DETECTION OF POSTTRAUMA
HAEMORRHAGE
•DECREASED PLT COUNT PREDICTS BODY CAVITY HAEMORRHAGE
Ref: JVECC (2014) 24:1 pp 93-104
TRAUMA PATIENTS OFTEN BLEED INTERNALLY
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WHAT DO WE KNOW?- MORE STATISTICS
• INCREASED LACTATE AND DECREASED BASE EXCESS PREDICT INCREASED MORTALITY
• aPTT WAS STRONGEST PREDICTOR OF DEATH IN ONE STUDY (SENS 67% SPEC 80%)
• STUDY RECENTLY- 13% RECEIVED GLUCOCORTICOIDS, 23% RECEIVED NSAIDS AND 3%
RECEIVED BOTH!!!!
Ref: JVECC (2014) 24:1 pp 93-104
BLOOD TESTS ARE GOOD! STEROIDS ARE BAD!!
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HOW DO WE KNOW IT?
• HUMAN STUDIES
• RELEVANT TO ANIMAL POPULATIONS?
• DIFFERENCES- PARAMEDICS, BLOOD AND CT SCANNING, INJURY PATTERNS?
• OTHER HUMAN POPULATIONS- CHILDREN IN DEVELOPING COUNTRIES
• HUMANS USE ANIMAL MODELS- TRANSLATIONAL MEDICINE.
• VETCOT= VETERINARY COMMITTEE ON TRAUMA
EVIDENCE BASED MEDICINE
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WHAT IS HAPPENING NOW?
• 26 ACTIVE VETERINARY TRAUMA CENTERS PARTICIPATING IN THE VETERINARY TRAUMA NETWORK
• A TOTAL OF 8,497 CASES HAVE BEEN ENTERED INTO THE TRAUMA REGISTRY TO DATE.
• VETCOT RESEARCH ON
• VALIDATING INJURY SCORES,
• PREDICTING TRANSFUSION REQUIREMENTS FOLLOWING TRAUMA
• PREVENTING HYPERFIBRINOLYSIS IN TRAUMA
MORE EVIDENCE BASED MEDICINE-COMING SOON…
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HOW CAN WE IMPROVE TRAUMA CARE?
• 1. TRAUMA PATIENT CARE
• IMPROVED SURVIVAL,
• REDUCTION OF COMORBIDITIES
• DEVELOPMENT OF PROTOCOLS TO IMPROVE EFFICIENCY AND OUTCOMES.
• 2. RESEARCH COLLABORATIONS
• DEVELOPMENT OF EVIDENCE-BASED MEDICINE PROTOCOLS
• EVALUATION OF MINIMALLY INVASIVE, COST-EFFECTIVE INTERVENTIONS
• TRANSLATIONAL MEDICAL OPPORTUNITIES)
• 3. EDUCATION ON VETERINARY TRAUMA
VetCOT The Veterinary Trauma Initiative
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TODAY’S FOCUS…
• BLUNT TRAUMA
• PATHOPHYSIOLOGY OF TRAUMA
• APPROACH TO TRAUMA CASES
• STABILISATION, MONITORING & INVESTIGATIONS
• NOT ORTHOPAEDICS!
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• WHAT IS STRESSFUL ABOUT TRAUMA?
TAKING THE TRAUMA OUT OF TRAUMA
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UNPREDICTABLE
DON’T say the
‘Q’ WORD!It is a well known fact that trauma cases are
most likely to occur
1) On a Friday afternoon
2) During breaks or attempted mealtimes
3) If anyone says it’s quiet
4) When you are short staffed and fully booked
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TRAUMA TRAINING
• MANY OF US DIDN’T GET THIS
• RECENT ADVANCES IN TRAUMA CARE
• FEELING ‘OUT OF OUR DEPTH’
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How
Can
Titanic
Help us
Save
Lives?
FEELING OUT OF OUR DEPTH?
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BE PREPARED…
PLAN & PRACTICE, PRACTICE, PRACTICE…
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TELEPHONE TRIAGE• TRAINING
• BRIEF DETAILS
• Contact Telephone Number
• ETA
• Animal’s Name/Surname
• Species (Breed also for dogs)
• FIRST AID INSTRUCTIONS (restraint, lifting,
bleeding)
• COMMUNICATION WITH CLINICAL STAFF
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PRE-ARRIVAL
• ORGANISE TEAM
• WHO DEALS WITH THE TRAUMA PATIENT
• WHO DEALS WITH THE OWNER
• WHO WILL DEAL WITH EVERYTHING ELSE…
• WATCH OUT FOR THE ARRIVAL
• GET STUFF OUT- O2 TENT/CHECK FULL OXYGEN/ IV CATHETERS/MONITORING EQUIPMENT
LOOK OUT FOR WHAT’S COMING…
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OWNER-ECTOMY
‘I’LL NEVER
LET GO…’(TITANIC MOVIE, 1997)
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TRIAGE – PRIMARY SURVEY
•MAJOR BODY SYSTEMS
• CNS- MENTATION, PUPILS, POSTURE
• RESP- AIRWAY, RATE, PATTERN, SOUNDS
• CARDIOVASCULAR-MM, CRT, HEART
RATE/RHYTHM/SOUNDS, PULSES & TEMP
• RECORD IT!
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TRIAGE – STABILISATION-A,B,C…
• A=AIRWAY #ET TUBE (ADVANCED AIRWAY
TECHNIQUES)
• B=BREATHING #OXYGEN #AMBU-BAG (CHEST
TAP)
• C=CIRCULATION #IV ACCESS (INTRAOSSEOUS,
JUGULAR)
• D=DRUGS=PAIN RELIEF
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CLIENT CARE
• OWNER
• INFORMED CONSENT
• UPDATES
• THE CONCEPT OF ‘SHOCK’
• OTHER CLIENTS
• KEEP INFORMED OF WAIT
• OFFER TO RESCHEDULE NON-URGENT CASES
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BE ‘KING OF THE WORLD’
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WHAT LIES BENEATH?
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TIME OF DEATH…
• 3 CRITICAL PERIODS WHEN PATIENTS DIE…
• IMMEDIATE- MINUTES
• INJURY TO BRAINSTEM, AORTA, HEART
• EARLY- HOURS
• HAEMORRHAGE, CNS INJURY
• LATE- DAYS
• COMPLICATIONS-INFECTION, MODS
}WE CAN SAVE THESE GUYS
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PATHOPHYSIOLOGY OF TRAUMA
2 HIT
HYPOTHESIS…
2 IMPACTS = FIRST HIT
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FIRST HIT
• FORCES APPLIED TO TISSUES
• STRETCHING
• COMPRESSION
• SHEARING
• MORE DAMAGE:
• MORE FORCE/ENERGY
• LESS ELASTICITY OF TISSUE
• LESS SURFACE AREA AVAILABLE TO ABSORB THE FORCE
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NEWTON’S 2ND LAW
FORCE = MASS x ACCELERATION
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HOLLOW ORGANS
• BLADDER, DIAPHRAGM, BOWELS, ALVEOLI
• COMPRESSION CAUSES INCREASED INTRALUMINAL PRESSURE
• POP!
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SOLID ORGANS
• SPLEEN, LIVER, KIDNEYS
• INTRACAPSULAR HAEMORRHAGE
• RUPTURED CAPSULE & HAEMORRHAGE
• SHEARING OFF OF VESSEL ATTACHMENTS- RAPID ACCELERATION-DECELERATION,
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HEAD TRAUMA
Coup Contre-coup
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LOOKING MORE CLOSELY: 2ND HIT
PARIS
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WHAT LIES BENEATH?
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SHOCK• DEFINITION: ‘INADEQUATE CELLULAR ENERGY PRODUCTION’
USUALLY DUE TO POOR TISSUE PERFUSION
Compensated Shock
• Mild-moderate mental depression
• Normal-prolonged CRT
• Tachycardia (or bradycardia in cats)
• Tachypnoea
• Normal pulses
• Normal blood pressure
Decompensated Shock
• Depressed/Collapsed
• Prolonged CRT
• Pale mucous membranes
• Weak peripheral pulses
• Decreased blood pressure
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TRAUMA DEATH TRIADcoagulopathy
Metabolic acidosisHypothermia
• VICIOUS CYCLE DUE TO SEVERE
HAEMORRHAGE
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HYPOTHERMIA
• HYPOTHERMIA BELOW 34° DECREASES COAGULATION PROTEASE FUNCTIONAL ACTIVITY AND PLATELET
AGGREGATION
• HYPOTHERMIA IS DUE TO POOR PERFUSION AND EXACERBATED BY ADMINISTRATION OF COOL IV FLUIDS
• MOST LAB TESTS ARE RUN AT NORMAL BODY TEMPERATURE
• MONITORING TEMPERATURE IS ESSENTIAL IN TRAUMA CASES
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ACIDOSIS
• ACTIVITY OF CLOTTING FACTORS REDUCED BY AS MUCH AS 50% AT PH 7.2
• METABOLIC ACIDOSIS IS CAUSED BY LACTIC ACID PRODUCTION PRODUCED BY
POORLY PERFUSED TISSUES
• LAB MACHINES TEST AT NORMAL BODY pH
• CAGESIDE LACTATE MACHINES USEFUL FOR MONITORING SHOCK AND EFFECTIVENESS
OF INTERVENTIONS
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COAGULOPATHYAcute Trauma Coagulopathy (ATC)
= systemic state of hypocoagulation and
hyperfibrinolysis.
Theoretical causes:
• severe tissue injury
• shock-induced hypoperfusion
• systemic inflammation
• endothelial damage
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MY TRAUMA PATIENT IS STILL BLEEDING BECAUSE…• A. IT HAS BLED OUT LOTS OF CLOTTING FACTORS AND PLATELETS
• B. IT HAS ALSO USED THEM UP TRYING NOT TO BLEED FROM ALL THE DAMAGED TISSUES
• C. IT HAS THAT WEIRD CLOTTING DISORDER FROM TRAUMA (ATC) WHICH GOES AROUND DISSOLVING
ALL THE CLOTS IT HAS ACTUALLY MANAGED TO MAKE AS WELL AS NOT WANTING TO CLOT
• D. CRYSTALLOID FLUIDS AND DILUTED THE REMAINING CLOTTING FACTORS
• E. IT IS TOO COLD
• F. IT’S BLOOD IS TOO ACIDIC
• G. ALL OF THE ABOVE!!!
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HOW DO WE KNOW WHAT LIES BENEATH?
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WHAT ARE WE LOOKING FOR?
•CONTINUED BLEEDING
•THORACIC INJURIES
•SEVERITY OF SHOCK
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TRILOGY OF TRAUMA TESTING
•BLOOD TESTING
•FAST ULTRASOUND TECHNIQUES
•MONITORING
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BLOOD TESTS
•LACTATE
•MINIMUM DATABASE (PCV, TS, GLU& BUN)
•ACID-BASE
•COAGS (PT & APTT)
•SMEAR (PLTS)
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MONITORING
•SPO2
•BLOOD PRESSURE
•ECG
•MOD GCS
•PAIN SCORE
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FAST SCANNINGNothing to do with the supermarket
FAST = Focussed Assessment with
Sonography for Trauma/Triage
Rapid technique for assessing trauma
patients
aFAST= abdominal FAST
tFAST=thoracic FAST
Also VetBlue (Veterinary Bedside Lung
Ultrasound Exam) an extension to tFAST
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AFASTPOSITION- Right lateral Recumbancy
4 VIEWS:
DH- just caudal to sternum
SR- left flank just caudal to last rib
HR- right flank just caudal to last rib
CC- just cranial to pelvis
Highly Sensitive and Specific for
Free Abdominal Fluid
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AFASTSpot the black triangles…
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TFASTTip!- use sternal recumbency in
respiratory compromised patients
and a roll of towel or paper towel
under forelimbs for better probe
contact
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TFAST
• TRAUMA WET LUNG =
PULMONARY CONTUSIONS
(UNLESS PROVEN
OTHERWISE)
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TFAST
Glide Sign
Helps rule out
pneumothorax
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TREATMENT
PRIMARY AIMS:
• PREVENT SUFFERING
• RESTORE & MAINTAIN PERFUSION TO VITAL ORGANS
• ENSURE ADEQUATE OXYGEN CARRYING CAPACITY OF BLOOD
SECONDARY AIMS
• DEFINITIVE TREATMENT OF INJURIES TO RESTORE FUNCTION
• PREVENT COMPLICATIONS
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PREVENT SUFFERING- ANALGESIAPure µ- opioids-
• Methadone
• Morphine
• Fentanyl
Reversible with Naloxone
Consider Regional Analgesia- line blocks
No to Steroids and NSAIDS
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PREVENT SUFFERING
•IMMOBILISE FRACTURES AND COVER WOUNDS
•CONSIDER BENZODIAZEPINES TO IMMOBILISE FRACTURES AND HEAD
TRAUMAS
•COMFORT/WARMTH/SLEEP/WATER/NUTRITION
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OXYGEN SUPPORT
O2 tent for cats Nasal Prongs for dogs > nasal oxygen catheter if need to stay on oxygen
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FLUID THERAPY
AIMS
• IMPROVE BLOOD PRESSURE TO PREVENT ORGAN DAMAGE (MAP>60mmHg)
• BUT NOT TOO HIGH OR RE-BLEEDING WILL OCCUR (MAP<70mmHg)
• FIELD PARAMETER OF IMPROVED MENTAL STATUS AND DORSAL PEDAL PULSE IN ANIMALS
• MAINTAINING PERFUSION HELPS PREVENT THE DEATH TRIAD
• CRYSTALLOID BOLUSES- LACTATED RINGERS SOLUTION
MONITOR BLOOD PRESSURE AND BLOOD LACTATE + PULSE QUALITY & MUCOUS MEMBRANES
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FLUID THERAPY• TISSUE OXYGENATION REQUIRES BLOOD OXYGEN CARRYING CAPACITY
• PACKED RED BLOOD CELLS
• WHOLE BLOOD
• (OXYGLOBIN)
• HYPOCOAGULATION REQUIRES CLOTTING FACTORS
• FRESH FROZEN PLASMA
• WHOLE BLOOD
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HEAD TRAUMA CONSIDERATIONS• PERFUSION OF BRAIN = MEAN ARTERIAL PRESSURE (MAP) – INTRACRANIAL PRESSURE
(ICP)
• TREAT HYPOTENSION FIRST
Increased ICP
SYSTEMIC BLOOD PRESSURE MUST BE HIGH ENOUGH TO PERFUSE BRAIN TISSUE SAP>90
Pushing blood into brain->
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DAMAGE CONTROL CONCEPT• HYPOTENSIVE RESUS TO ALLOW ADEQUATE PERFUSION WITHOUT DISRUPTING
THROMBUS FORMATION.
• FRESH WARM BLOOD>BLOOD PRODUCT COMBO (PRBC, PLASMA,
PLATELETS)>CRYSTALLOIDS
• THE CHALLENGE IS NON-COMPRESSABLE HAEMORRHAGE
• NEED EARLY IDENTIFICATION
• NOT EVERYWHERE HAS LOTS OF BLOOD PRODUCTS AND PERSONNEL
• IF CANNOT STABILISE OR RELAPSE INTO SHOCK NEED SURGERY IMMEDIATELY
Following major haemorrhage…
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HAEMOSTATIC RESUSCITATION• SEVERE HAEMORRHAGE REQUIRES HAEMOSTATIC RESUSCITATION
• BLOOD PRODUCTS INCLUDING
• SHED BLOOD (AUTOLOGOUS BLOOD TRANSFUSION)
• WHOLE BLOOD
• BLOOD COMPONENT THERAPY - RECOMMENDED 1:2 FFP:PRC
• WARMING
• IDENTIFY SOURCE & SECONDARY SITES, APPLY DIRECT PRESSURE/ABDOMINAL WRAP
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ABDOMINAL WRAP• Include the hindlimbs!
• Use upto 48 hours with pressure of
20-25mmhg (to avoid abdominal
compartment syndrome)
• Survival rates increase using this in
haemoperitoneum.
• Contraindicated if diaphragmatic
hernia is present-pushes organs
into chest
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AUTOLOGOUS BLOOD TRANSFUSION
Empty fluid bag with attached
giving set
20ml syringe
Large bore needle
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AUTOLOGOUS BLOOD TRANSFUSION
POTENTIAL COMPLICATIONS/PRECAUTIONS
• INFECTION- ALTHOUGH ONE STUDY SHOWED EXCELLENT SURVIVAL EVEN WITH CONCURRENT BOWEL
PERFORATIONS
• NEOPLASTIC METASTASIS
• USE AN INLINE FILTER OR BLOOD ADMINISTRATION GIVING SET
• FOLLOW UP WITH FFP
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AUTOLOGOUS BLOOD TRANSFUSION• TAKING SHED BLOOD FROM THE ABDOMEN OR THORAX AND TRANSFUSING IT
• In <1 hour the blood will have undergone
fibrinolysis- no anticoagulant required!
• Readily available source of pre-warmed type-
specific blood
• Collection is easy!
• Can give as fast as you want (don’t use a fluid
pump)
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DAMAGE CONTROL SURGERY
• NOT definitive repair
• Aim is to control haemorrhage
• ‘Get in, Get out’
• Pack Abdomen, temporary closure
• ICU then second surgery
State of the art…
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IMPORTANT POINTS
•BE PREPARED
•CHECK WHAT IS GOING ON BENEATH THE SURFACE
•PRACTICE FAST SCANNING
I want to be able to honestly tell the owner (and myself), ‘I did everything I could’
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QUESTIONS????
Thanks for listening!