Severe trauma, severe bleeding and therapy, brain injury, intracranial hypertension, brain death, donor program Zdeněk Chvátal KARIM FN Brno Severe trauma Definition •Multiple trauma: injury of at least two organ systems, of which at least one is life-threatening •Severe trauma is defined by an Injury Severity Score (ISS) >15 Injury severity score •Trauma scale used to grade severity of multiple injuries and based on AIS (abbreviated injury score) •Evaluation based on anatomical injury •Anatomical regions: • Head or neck,Face ,Chest ,Abdomen or pelvic contents, • Extremities or pelvis, Surface of the body •Severity: none=1( contusion of back), minor=2 (forearm fracture), moderate=3(fracture of the skull base without likvorea), serious=4(burn of 3th degree on 30% of the body surface), severe=5(fracture of the cervical vertebra with quadruplegic), critical=6(decapitation) •Calculation: ISS = A2 + B2 + C2 (3 the most injured) Mechanisms of injury •Blunt •Penetrating •Thermal (burns and cold injury) •Blast Epidemiology and ATLS •250 per million population per year •Advanced trauma life support (ATLS) •training program for medical providers in the management of acute trauma cases, developed by the American College of Surgeons •its goal is to teach a simplified and standardized approach to trauma patients •widely accepted as the standard of care for initial assessment and treatment in trauma centers •The premise of the ATLS program is to treat the greatest threat to life first (A, B, C, D, E…..) • ATLS, the way of thinking The team approach in trauma centers •Team leader (anesthesist intensivist, surgeon…) •Trauma surgeon, general surgeon •Intensivist, anesthesist •Radiologist •Optional: •Neurosurgeon, neurologist, urologist, neck-, face surgeon, urologist… • Generic approach to trauma care •Detection and treatment of life-threatening injuries during a primary assessment and intervention phase. •Detection of all the other injuries during a secondary assessment ( head to toe examination) when a more detailed clinical examination is combined with investigations such as imaging. Definitive care plans are then made. •Detection of missed injuries and early sequelae or complications (i.e. compartment syndrome after tibial fracture) in a tertiary assessment, performed within the next 24 hours. • Assumption of severe trauma •Falls >2 metres •Pedestrian or cyclist hit by a car at speed >30 km/hr (18 miles/hr) •Death or severe injury of another occupant in the same vehicle/accident •Ejection from a vehicle •Major deformity of the vehicle or intrusion into the passenger space, especially bent columns around the front doors •Extrication time >20 minutes •Vehicle roll-over •Penetrating injury to the head or trunk Bases of the ABCDE approach A- Airway maintainence with C spine protection •fiO2 need •Airway patency- •Obstruction •coma •Spontaneous ventilatory activity •Airway obstruction signs: •Stridor •Ineffective breathing attempts •Causes of obstruction •Foreign body •Trauma to the neck •Burns- inhalation trauma B- Breathing and ventilation •Tension pneumothorax •Open pneumothorax •Massive haemothorax •Flail chest +pulmonary contusion Open Pneumothorax •collection of air in the pleural cavity resulting in collapse of the lung on the affected side •follows a penetrating chest trauma such as a stab wound, gunshot injury of fractured rib •breathing shallow,rapid,laboured.Reduced expansion of the hemithorax •sucking chest wound – visibly bubbling •first aid:cover the wound with non-occlusive dressing,definitive: chest drain insertion Open Pneumothorax open_sucking_pneumothorax1327819647872.jpg Pneumothorax DSC01938 Tension Pneumothorax •develops when a one-way valve air leak occurs from the lung or through the chest wall •air is forced into the thoracic cavity without any means of escape •mediastinum is displaced to the opposite side, decreasing venous return and compromising the opposite lung •chest pain,air hunger, tachycardia, hypotension, tracheal deviation, cyanosis, neck vein distention, unilateral absence of breath sounds •requires immediate decompression and chest drain • insertion Tension Pneumothorax tension_pneumothorax1327819951401.jpg Needle Decompression medrills-ncd-for-pneumothorax-34-2-s-307x512.jpeg Chest Drain Insertion chest-tube-drainage-drtinku-joseph-23-638.jpg chestdrain03.jpg Flail Chest and Pulmonary Contusion •chest wall does not have bony continuity with the rest of the thoracic cage •unilateral fractures of four or more ribs or bilateral •chest wall instability leads to paradoxical motion of the chest wall •underlying lung injury- pulmonary contusion • Massive Hemothorax •accumulation of blood in a hemithorax (>1500ml) •may significantly compromise respiratory efforts by compromising the lung and preventing adequate ventilation •C-more dramatically present as hypotension and shock •decreased breath sounds,signs of shock (pulse rate, respiratory rate,skin circulation) • •it is necessary to place the chest tube and check the bood loss • • • • Hemothorax Th Cardiac Tamponade •penetrating injuries •small amount of blood in the pericardial sac • will restrict cardiac • activity • pericardiocentesis • • •Hypotension with a narrowed pulse • pressure •Jugular venous distention •Muffled heart sounds • 08_Cardiac_Tamponade_3_V2.jpg Treating breathing problems •Oxygen •Intubation, mechanical ventilation •Chest tubes •Analgesia C- Circulation with haemorrhage control •Hypotension following injury must be considered to be hypovolemic in origin until proven otherwise •Skin color,pulse,level of consciousness •FAST (Focused Assessment with Sonography for Trauma ) • •Types of shock: ?????? •Hypovolemic Haemorrhagic shock •Obstructive tension pneumothorax •Cardiogenic Cardiac contusion- •Distributive - SIRS • • FAST scan • •fast,non-invasive •rules in,not out •can be repeated fluid-and-blood-resuscitation-in-abdominal-trauma-2-728.jpg Severe bleeding Treating circulation •Two large peripheral intravenous lines •Fluid resuscitation •Beware of over-resuscitation •Accept a lower pressure target - SBP 80-90mmHg ( without brain injury) •Haemotherapy Life-threatening haemorhage •Definition: Blood loss associated with the impairment of tissue perfusion, severe hypotension, shock and multiple organ failure a) loss of total circulating blood volume with the need of substitution with as much as 10 TU erytrocyte concentrates in 24 hodin. b) loss of 50% of total circulating blood volume in 3 hours c) bleeding exceeding 150 ml/min d) depending on the localization: bleeding into vital organs, regardless of quantity (eg. CNS bleeding, airway bleeding, pericardial bleeding, aortic dissection…) C:\Users\30450\Desktop\Blood loss.jpg hypothermia Heamostasis disorders treatment •Damage control surgery •Treat: •Shock •Acidosis •Hypothermia •Substitution of thrombocytes and heamocoagulation factors •Antifibrinolytics Management of Coagulopathy of trauma •Hypothermia, electrolyte disorders: – hypotermia underpod 35°C has a negative influence on coagulation cascade and platelet aggregation. Patient rewarming, infusion warming… - correction of Na, K, Cl, Mg, P, HC03, especially Ca2+ and pH •Treating coagulopathy: -Fresh frozen plasma – in a ratio of ER to FFP 1:1 -platelets – target value of >100. Therapeutic dose 1 TU from aferesis, or 6-8 TU of pooled Tr. -fibrinogen - PCC protrombin complex concentrate -activated recombinant factor VII (rFVIIa) - after failure of standard management Management of Coagulopathy of trauma •Coagulation monitoring implemented as early as possible following traumatic injury and used to guide haemostatic therapy. •A damage control approach to surgical procedures should guide patient management, including closure and stabilisation of pelvic ring disruptions, packing, embolisation and local haemostatic measures. •Use appropriate physiological targets and use and dosing of fluids, blood products and pharmacological agents in the bleeding trauma patient. •The growing number of older patients requires special attention to appropriately manage the inherent thromboembolic risk profiles and possible pre-treatment with antiplatelet agents and/or oral anticoagulants. •A multidisciplinary approach to the management of the traumatically injured patient remains the cornerstone of optimal patient care, and each institution needs to develop, implement and adhere to an evidence-based management protocol that has been adapted to local circumstances. •The management of acute bleeding is a complex challenge • •Bleeding mostly occurs during and after surgical intervention or trauma where secondary alterations are added (haemodilution,hypothermia,acidosis,anemia,hypoperfusion) • •clinical significance of the routine coagulation tests is rather weak • •interest in methods, which better reflect haemostasis ROTEM® shaped view…. TROMBOELASTOMERY •ROTEM® delta Delta-ohne-Plat.jpg •overview •viscoelastometric method • •point – of – care testing • •whole blood analysis • • - time to clot formation • • - speed of clot formation • • - clot lysis • • • •basic principle detection-principle-en-800px.jpg •ROTEM® curve •citrated blood into a cuvette • •cylindrical pin immersed • •gap bridged by the blood • •pin rotated by a spring • •clot restricts the rotation • •optical detection • • PARAMETR DESCRIPTION CT- clotting time initiation of clotting,trombin formation, start of clot polymerisation CFT- clot formation time fibrin polymerisation, stabilisation of the clot with plt and XIII MCF – max clot firmness increasing stabilisation of the clot by the polymerised fibrin,plt and XIII ALFA-angle describes the kinetic of the clotting A10- amplitude 10 min after CT fast prediction of clot firmness ML – maximum lysis stability of the clot or fibrinolysis (15%) LI30 – lysis index 30min after CT fast prediction of lysis temogram-en-800px.jpg  ASSAY INFORMATION PROVIDES EXTEM activation of clot formation by tromboplastin assessment of the factors: VII,X,V,II,I,plt,fibrinolysis INTEM activation of the clot formation via the contact phase assessment of the factors:XII,XI,IX,VIII,X,V,II,I,plt,fibrinolysis FIBTEM as EXTEM+platelets blocking substance assessment of fbg level and fibrin polymerisation APTEM as EXTEM+fibrinolysis inhibitor hyperfibrinolysis can be recognised within 10-20 min HEPTEM as INTEM+heparinase heparin related coagulopathy can be recognised NORMAL PATIENT • PLATELETS DEFICIENCY • FIBRINOGEN DEFICIENCY • HYPERFIBRINOLYSIS • HEPARIN INFLUENCE • • drug induced plt dysfunction (ASA,CLOPIDOGREL) • •impairment of primary hemostasis (vWD) • • direct thrombin and fXa inhibitors : • (DABIGATRAN,RIVAROXABAN) • • coagulation under conditions of flow and impaired haemostasis due to disturbed preconditions of haemostasis • (Hg,ion.Ca,pH,core temperature) •standard laboratory tests were designed to test for factor deficiencies, not for predicting risk of bleeding or guiding haemostatic management • •viscoelastic monitoring enables rapid intraoperative diagnosis of the cause of bleeding Screen Shot 2015-09-12 at 16.23.25.png D - DISABILITY •Level of consciousnes •Pupillary size and reaction •Lateralizing signs •Spinal cord injury level Traumatic brain injury 11342576895epiduraltrauma ICP •Elevated IPC may reduce cerebral perfusion and cause ischemia • •Monro-Kellie Doctrine (three noncompressive parts enclosed in the skull – liquor, blood and brain tissue •CPP=MAP-ICP • (50-70mmHg) Principles of TBI treatment •ABCD •Evacuation of mass-lesion •Prevention of secondary injury – intracranial hypertension treatment •ICP monitoring •Head elevation •sedation •osmotic therapy (concentrated NaCl, manitol) •ventriculostomy •Mild therapeutic hypothermia •hypocapnia (hyperventilation) •Barbiturate coma •Decompressive craniectomy • • D - DISABILITY •Spinal cord injury: • •respiratory arrest- Q: why? •Interruption of the the phrenic nerve supply •neurogenic shock: •hypotension but with warm extremities- Q: why? •loss of sympathetic (vasoconstrictor) tone •Bradycardia- Q: why? •Loss of the sympathetic nerve supply to the myocardium Damage control •Addresses bleeding and contamination promptly •Objective: interrupt the downward spiral of acidosis, coagulopathy and hypothermia •Involves rapid surgery to stop bleeding and decontaminate wounds, deliberately postponing definitive repair until physiological stability has been re-established > The phases of damage control •Initial assessment and stabilisation in the Emergency Department •Immediate, limited surgical intervention: haemorrhage and contamination are controlled using temporary methods- closure and stabilisation of pelvic ring disruptions, packing, embolisation and local haemostatic measures. •Continuing stabilisation on the ICU: physiological system control, monitoring for wound complications (e.g. abdominal compartment syndrome, if the abdomen has been closed) and continual vigilance for missed injuries. •Re-operation: definitive repair can now take place. If the original wound was left open at the initial operation, wound closure and definitive repair may be possible now. Brain death •Irreversible absence of brain stem function despite arteficial maintanence of circulation and gas exchange •Guidelines for withdrawal of artificial support and, where possible, preparation of organ donors Clinical signs of brain death •The pupils don’t respond to light. •The person shows no reaction to pain. •The eyes don’t blink when the eye surface is touched (corneal reflex). •The eyes don’t move when the head is moved (oculocephalic reflex). •The eyes don’t move when ice water is poured into the ear (oculo-vestibular reflex). •There is no gagging reflex when the back of the throat is touched. •The person doesn’t breathe when the ventilator is switched off. •An electroencephalogram test shows no brain activity at all. CONFIRMATION OF BRAIN STEM DEATH •Loss of all brain stem refexes •examination by two doctors independent of each other • •Diagnosis of brain death have to be confirmed by examination -Angiography of brain artheries -CT angiography • - Brain perfusion scintigraphy • - BAEP brain stem auditory evoked potentials • - Transcranial doppler ultrasonography • Rules for Organ donor ( Czech republic) •Controlled by law ( no.285/2002) •Organ removal is possible 2 hours after confirmation of deathIt •Is necessary follow ethical principles •Everybody in the Czech republic is potential donor Thanks for your attention …..be careful and protect yourself