TRAUMA AND SURGICAL RESUSCITATION SEMINAR

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TRAUMA AND SURGICAL RESUSCITATION SEMINAR

• Matthew Croxford
• Colorectal General Surgeon
• Western Health
• Chief Medical Officer
• Motorsport Safety Rescue

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Seminar Objectives

• Describe symptoms signs of shock haemorrhage
• Post-op setting
• Trauma setting
• Take appropriate measures to resuscitate a
  patient with haemorrhage
• Assess need for ongoing monitoring of
  resuscitative measures
• Recognise importance of a team approach the
  need to mobilise support

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SHOCK
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SHOCK

• Definition
• Decrease in tissue perfusion to a point at which
  it is inadequate to meet cellular metabolic needs

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SHOCK
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SHOCK
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EFFECTIVE MANAGEMENT

• Initial step in management recognise its
  presence!
• Second step identify the probable cause
• Initiate treatment simultaneously with attempt to
  identify the probable cause

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Case Scenario 1

• You receive a trauma call to the ED paramedics
  have called they will be arriving in 4 minutes
  with a 34 year old patient with a BP of 80
  systolic and a stab wound to the back between the
  shoulder blades
• What form of shock might he be suffering from?
• Haemorrhagic shock?
• Pump failure due to cardiac tamponade?
• Pump failure due to tension pneumothorax?
• What action may be necessary?
• Depends on cause BUT
• Immediate attention to ABCs, oxygen, IV fluids
• Diagnosis and definitive management

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CLINICAL FEATURES

• Follow a logical sequence
• Primary Survey
• A - Airway (Cx spine control)
• B - Breathing and ventilation
• C - Circulation with haemorrhage control
• D - Disability Neurological status
• E - Exposure/Environmental control
• How are you?

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A - Airway

• Look
• Central cyanosis
• See-saw or abdominal breathing
• Accessory muscles
• Tracheal tug
• Altered conscious level
• Airway obstruction
• Listen
• Grunting, snoring, hoarseness, stridor
• Feel
• Airflow on inspiration expiration

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B - Breathing

• Look
• Cyanosis/accessory muscles
• Respiratory rate
• Sweating
• Raised JVP
• Patency of chest drains
• Remember O2 sats do not detect hypercapnia

• Listen
• Noisy breathing
• Clearance of secretions
• Ability to talk in sentences
• Percussion note
• Auscultation
• Feel
• Position of trachea
• Surgical emphysema or crepitus

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C - Circulation

• Hypovolaemia until proved otherwise
• Haemorrhage must be rapidly excluded
• Overt or covert
• Unless obvious signs of cardiogenic shock
• Cool tachycardic hypovolaemic shock

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C - Circulation

• Look
• Reduced peripheral perfusion
• Pallor, coolness, collapsed veins
• BP may be normal
• External haemorrhage wounds, drains
• Concealed haemorrhage beware the empty drain
• thoracic, abdominal, GI tract, pelvic or femoral
  
• Altered conscious level
• Cerebral perfusion
• Feel
• Pulses peripheral and central
• Rate, quality, regularity, equality

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Class I Class II Class III Class IV
Blood Loss (ml) Up to 750 750-1500 1500-2000 gt2000
Blood Loss () Up to 15 15-30 30-40 gt40
Pulse Rate lt100 gt100 gt120 gt140
BP Normal Normal Decreased Decreased
Pulse pressure Normal or increased Decreased Decreased Decreased
Resp Rate 14-20 20-30 30-40 gt35
Urine Output gt30 20-30 5-15 Negligible
Mental State Slightly anxious Mildly anxious Anxious, confused Confused, lethargic
Fluid Replace Crystalloid Crystalloid Crystalloid blood Crystalloid blood
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D - Disability Neurological Status

• Pupils / GCS
• AVPU system
• A Alert
• V responds to verbal stimulus
• P responds only to pain
• U unresponsive to any stimulus
• Sedatives, analgesics, anaesthetic drugs
• Hypoglycaemia
• Review the ABCs missed something

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E - Exposure

• Patient must be adequately exposed
• Avoid hypothermia
• Warm blankets/warming device
• Warmed IV fluids
• Respect dignity
• If at any time the patient deteriorates
• Reassess the ABCs

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Case Scenario 2

• An 81 year old woman with diabetes is admitted to
  the ward for routine observation after a
  straightforward balloon dilatation of a stenosis
  in her left common iliac artery.
• As the Intern, you are called by her nurse as her
  Pulse was 80 and BP was 100/60 and she looked a
  little pale.
• How would you respond?

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Case Scenario 2

• Examination shows the above observations but she
  is also peripherally shut down.
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• What else would you do?
• Review of left leg showed no swelling at femoral
  puncture site and weak distal pulse. Some mild
  discomfort in left iliac fossa.
• Review of her medication chart reveals
  beta-blockers and pre-procedure BP of 160/90.
• What now?

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Case Scenario 2

• Non-sustained response to 500ml bolus fluid.
• What now?
• Laparotomy reveals large bleed from ruptured
  common iliac artery.
• What is role of CT scan here?

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Management

• Assume UNDERVOLUME is the cause unless
• Obvious cardiogenic cause
• Tension pneumothorax (raised JVP)
• STEP 1 Resuscitate
• STEP 2 Review response
• STEP 3 Report to involve senior colleagues

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Management

• AIRWAY
• Protected in all, secured if potentially
  compromised
• Jaw thrust/chin lift
• Nasopharyngeal/oropharyngeal airway

• BREATHING/OXYGENATION
• ETT or surgical airway
• Supplemental O2 in ALL cases
• Pulse oximetry
• Tension pneumoTx
• Immediate chest decompression

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Management

• CIRCULATION
• Control bleeding external pressure/operative
  intervention
• 2 large bore IV cannulae (14G 2x flow of 16G)
• Upper extremity peripheral is best (CVC/cut down)
• Type X-match/Hb/clotting
• Rapid infusion of crystalloid/colloid
• 500ml bolus may need 2-3 litres in adult trauma
• Type-specific or O-negative blood
• Do NOT use vasopressors

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Adjuncts to Management

• ECG monitoring
• Dysrhythmias may indicate aetiology
• Urinary catheter
• Indicator of volume status/renal perfusion
• Beware urethral injury in trauma setting
• NG tube
• Decrease risk of aspiration

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Adjuncts to Management

• Monitoring
• Ventilatory rate ABGs
• Pulse oximetry
• Blood pressure
• Body temperature
• Urine output
• Look for return of normal peripheral perfusion

• X-Rays Diagnostics
• Chest/Pelvis/Lateral Cx spine
• Remember a normal Cx spine XR does not exclude an
  injury
• FAST scan
• CT scan
• Beware the unstable patient in radiology

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Response to Resuscitation

• Frequent re-evaluation
• Cardio-respiratory parameters
• Urine output - gt0.5 ml/kg/hr
• Repeated clinical examination
• Look for new findings
• Relief of severe pain
• Titrate dose smallest effective dose
• Avoid resp depression or masking subtle injuries

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Refractory Shock

• Underestimation of degree of hypovolaemia
• Failure to arrest haemorrhage
• Presence of tamponade or tension pneumothorax
• Underlying sepsis
• Secondary CV effects due to delay in treatment
• Further action is necessary!

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Case Scenario 3

• A 35yr old woman underwent an uncomplicated
  laparoscopic cholecystectomy eight hours ago. You
  are the night Intern and are called by the nurse
  as the patient is anxious, and is complaining of
  right shoulder tip pain.
• How will you respond?
• Her obs. are P 120, BP 90/50, RR 21 and Temp 37.0
• 40 ml haemoserous fluid in Redivac drain bottle.
• What now?

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Post-op Patient

• THINK SURGICAL FIRST BLEEDING Involve the
  surgical team
• Examine the patient
• Examine the charts
• Trends in PR, BP, RR, urine output, epidural
  doses
• Look at the fluid balance chart
• Think of other causes
• Septic shock
• Inadequate replacement of fluid losses
• Effects of opiates, epidurals,
• Non-surgical causes AMI, PE, dysrhythmias

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Case Scenario 4

• A 69 yr old man has undergone TURP three hours
  ago and has just returned to the ward.. The nurse
  rings you as she is not happy with the way he
  looks as he is shaking uncontrollably. You are
  scrubbed in theatre when she rings.
• How would you respond?
• His observations wereP 110, BP 95/60, T 38.5,
  returned fluid in urinary irrigation bag was
  pink in colour with no clots.
• What is your differential diagnosis?
• How to proceed from here?

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Case Scenario 5

• A 23 yr. old trail bike rider has been brought in
  to the Emergency Department by his mates with
  what looks like a fractured right femur. There
  has not been any loss of consciousness but he is
  complaining of some diffuse abdominal pain.
• His observations on arrival were P 90, BP 110/50,
  RR 18. You have been asked to assess him and to
  insert an I/V. His right femur is clinically
  fractured and the abdomen is diffusely tender and
  non-distended There are no other injuries
  apparent but you have difficulty with the IV
  insertion as his veins seem to be collapsed.
• What do think is going on here?
• What treatment plan would you write-up?
• What investigations should be undertaken and how
  quickly would you want them done ( it is very
  busy in ED tonight ) ?

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Summary

• Structured system of assessment reduces serious
  omissions
• Identify those in need of immediate life-saving
  resuscitation
• Assess and treat simultaneously
• Reach a diagnosis to account for clinical
  deterioration
• Formulate and institute a plan of definitive
  treatment

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Summary

• Repeated clinical assessment is the cornerstone
  of good practice
• Investigations should be selective and carried
  out in a safe environment
• Inform and involve your senior colleagues at an
  early stage
• Consider the level of care necessary at each stage

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