The latest changes in evidence in clinical management of ...docs2.health.vic.gov.au/docs/doc... ·...

The latest changes in evidence in

clinical management of trauma

Emergency Care Clinical Network

Associate Professor Rodney Judson

Director of Trauma

The Royal Melbourne Hospital

Outline

• State Trauma System

• Trauma resuscitation

• Early trauma care

▫ Triage

▫ Transfer

• Surgical Decision making

Victorian State Trauma System

• Implemented in 1999

▫ MTS now caring for 80% of major trauma patients

▫ Decreased inpatient hospital mortality from 15% to 11%

Success of Trauma System

State Trauma System

• Evolution of the system included

▫ Development of guidelines

▫ Refinements of the system

Via state trauma registry data/ meetings and reports

State Trauma System

• Development of guidelines

▫ Major trauma triage guidelines

Review resulted in:

prehospital trauma triage time to MTS changing from 30 to 45 mins

Change in vital signs to ensure 80% capture of MTS patients at scene

State Trauma System

• Validated prehospital triage of based on

▫ Vitals signs

▫ Injuries

▫ High Risk Mechanism

• Transfer to MTS time

▫ 45 mins

State Trauma System

Inter-Hospital Trauma Transfer

Vitals now the same as prehospital due to validation study

State Trauma System

• Adult Retrieval Victoria (ARV) ▫ Adult Retrieval Victoria is a single contact point for: Major Trauma

Critical Care Advice

Critical Care Bed Access

Retrieval of Critical Care Adult Patients State-wide.

▫ This state-wide service is available 24 hours, 365 days

a year.

Trauma Resuscitation

• To intubate or to not intubate

▫ Prehospital RSI randomised controlled trial Outcome: Severe TBI pts with prehosp RSI had

favourable outcomes at 6 months

▫ Bernard et al 2008


• Permissive hypotension

▫ Hypotensive resuscitation and /or low volume resuscitation

Remain controversial in Australia

Part of damage control resuscitation along with

damage control surgery and haemostatic resuscitation

Targets SBP ≥ 70 & ≥ 90 with head injury


• Permissive hypotension ▫ Problems Not widely accepted in Australia Studies based on animals mostly Varying interpretations Must not miss non haemorrhagic causes (ie PTX

etc) Prolonged retrieval times in Australia > 6hrs Concerns if ? Severe TBI Appropriate BP varies patient to patient

• No High level evidence to support this


• Research says haemorrhage leading case of death

▫ Accounts for up to 80% of deaths in operating room

▫ Exsanguination noted internationally as the “leading cause of early hospital death”

RMH data 2013-2014 financial year

haemorrhage as principle cause of death in 1.42 %


• Trauma Induced Coagulopathy (TIC)

▫ Systemic anticoagulation

▫ Fibrinolysis

Exacerbated by hypothermia, acidosis and haemodilution

• Coagulopathy present in up to ¼ of trauma patient

• Fluid resuscitation causes cellular changes

• Damage control resuscitation

▫ Improves haemostasis

▫ Haemorrhage control

▫ Limit haemodilution

▫ Hypothermia

▫ Improve outcomes


• Change in Blood component therapy

▫ Early transfusion of Blood and blood components= early haemorrhage control

• Transfusion strategies

▫ Transfusion ratio 1:1:1

{ 4 units of RBC’s, 4 units (2 bags or 600mls) of FFP & 4 units (1 pooled/ aphorised bag) of platelets}

The Guideline Trauma Call

Primary Survey

A: Patent airway & C/spine protection

B: Ensure adequate breathing, circulation & oxygenation

C: Venous access 2 large bore cannualae; inspect for sources of bleeding

(take baseline bloods (Xmatch, FBC, Coags, Biochem)

D: Conduct GCS

E: Commence hyopthermia protocol: warm fluids & bare hugger

External Long Bones

CXR & PXR < 10 mins

DPA +/-FAST < 30mins

Interventions

Apply pressure

Splint long bones

Chest tubes

Trauma Laparotomy

Pelvic sling

Angiography

Massive Transfusion Trigger?

ABC Tool > or = 2

> 4units ~4 Hours

Continue with

Primary and

secondary

survey

Bolus 1 to 2 litres

warm crystalloid solution

Commence RBC's O Negative

(ensure bloods have been sent)

Initiate MEP 1

Blood Bank Telephone

27275 or 27276

Unknown patient protocol activated if relevant

Commence documentation on the Massive Transfusion Sheet

MEP 1 contents

4 units O Rh (D) Negative Red Cells

2 units FFP = 1 bag

4 units of Platelets = 1 pool

Massive Transfusion Fluid Balance Sheet

If theatre

required

urgently

initiate

Trauma

OPSTAT

Transfusion Triggers

Platelets < 75 x 10 9/L= 1 bag of plts

Platelets < 50 x 10 9/L = 2 bags of plts

INR > 1.5 = 2 bags FFP

INR > 2.0 = 4 bags FFP

Fibrinogen < 1.5g/L = 6 bags of cryo



Consider NovoSeven

Inconsultation with heamatology registrar

Inclusion

persistent uncontrolled heamorrhage

not managed by stabilistiaon, surgical

exploraiton or transfusion

Exclusion criteria

Ph < 7.15

Temp < 34 degrees

MEP PACK TWO

Blood Bank Telephone 27275 or 27276

And notify of patient location & clinical status

MEP 2 onwards contents


4 units FFP = 2 bags

4 units Platelets = 1 pool


MEP PACK THREE

Contents same as MEP 2

Resuscitation Endpoints

Haemostatic Control

INR 1.5 or less

Fibrinogen 1.5 or more

Platelets > 50 or > 100 if critical structures

at risk of bleeding

PH > 7.20

SBP: 80-90 mmHg

Temperature > 36 degrees

On release of MEP 1

Blood bank notifies

Heamatology registrar who

will Telephone the Trauma

Team Leader in ED

on ext 24890

with the first coagulation

sample results

Release group

specific

products

ABC Tool

Penetrating Mechanism

ED SBP < 90mmHg

ED HR > 120 bpm

Positive Fast

No

Remember it can take

> 30mins to thaw FFP & Cryo

Yes

Minimise Crystalloid

Continue resusitation based on clinical parameters and ongoing bleeding

(ensure post administration bloods have been taken and sent)





Initiate MEP 1

Blood Bank Telephone

27275 or 27276

Unknown patient protocol activated if relevant

Commence documentation on the Massive Transfusion Sheet

MEP 1 contents


2 units FFP = 1 bag

4 units of Platelets = 1 pool



• Tranexamic Acid

▫ Crash 1 and 2 trials

Outcome

Early administration of TXA safely reduces risk of death in bleeding patients and is highly cost effective

$30 dose

~ 3 hrs of injury admin

▫ Outcomes

All cause mortality

16 % to 14.5%

Risk of death from bleeding was 5.7% to 4.9%

▫ RMH 1.42%


• Many took this as definitive evidence have added TXA into protocols

▫ CRASH 2 Concerns

< 2% of cases treated in countries with modern trauma care standards

Access to blood and blood products, angiography and critical care

Baseline mortality was 16% even though only half received blood

VTE concerns rates increased 9-12 time in those who received TXA


▫ Pre-Hospital Anti-fibrinolytics for Trauma Coagulopathy and Haemorrhage study (PATCH)

NHMRC funded Australia and New Zealand

Test the effect on mortality and recovery at 6 months

Include: coag, fibrinolysis, transfusion, VTE, immunity and sepsis


• Proposed practice changes to inadequate perfusion guideline

▫ Arterial tourniquets

Bleeding limbs that cannot be managed simple pressure

▫ Vasopressors

In Traumatic brain injury unresponsive to resuscitation to maintain CPP

Target SBP 120mmHg

Early Trauma Care

• Spine immobilisation methods

▫ No randomised controlled trials

▫ Effect of immobilisation on trauma patients remains uncertain

Early Trauma Care • Spine immobilisation prehospital

▫ There is insufficient evidence to support treatment guidelines in prehospital N/Surg 2002

• Prehospital immobilisation criteria

▫ (AV 2012 clinical practice guidelines) Age >55 History of bone disease Decreased GCS Drug of ETOH Significant Distracting injury Spinal column pain/ tenderness Neuro deficit

• Not for use in paediatrics

•

Early Trauma Care

• Cervical Spine Clearance ▫ Cervical Spine injury incidence in blunt 14% 92% are fractures & 14% ligamentous injuries

▫ RMH Trauma Registry Report 2013-2014

▫ CT scan is “gold standard” for assessment with

100% detection of bony injuries (Vanguri et al 2014)

▫ However limited in soft tissue assessment MRI more sensitive but timing is important Sensitivity decreases ~ 72hrs

Early Trauma Care

• RMH cervical spine clearance 2014 Study

▫ demonstrated average of 11.3 hrs to spine clearance, Median and Mode 5hrs

▫ No incidence of pressure sores related to cervical collars

• RMH over all since 1999 we have had a 90% decease in time to clearance and 100% decrease in collar related pressure injuries

RMH time to spinal clearance

64 61

95

25

193

100

119

86.49

95.84

49.12

25.5

11.3

0

20

40

60

80

100

120

140

160

180

200

1999 2000 2001 2002 2005 2013

Patients

Average Hours

Early Trauma Care

Symptomatic treatment in cervical collar with referral to Orthopaedic unit

+/- MRI (MRI most sensitive < 72 hrs to

ligamentous injury)

Patient clinically assessed

as having full range of motion of their cervical

spine with no pain and assess as to high risk

criteria?

CT NAD

No

Yes

Yes

No

Cervical Spine Helical CT Occiput to T1

Yes to any

NEXUS criteria

Is there any: Reduction in conscious state / alertness?Intoxication?Posterior midline tenderness?Focal neurological deficit?

Painful distracting injury?

Potential Cervical Spine InjuryMaintain Spinal Precautions

No to all

Spine "cleared"

Collar off

Document on spinal management

chart/ symphony and

or medical record

High Risk of Ligamentous Injury

elderly > 65

Advanced degenerative disease

TL fracture

Multidirectiona forces

ejection

Axial Load

Fall > 3 metres or 5 stairs

Quad bikes/ Bikes

Early Trauma Care • Standard needle decompression

▫ Normal IV catheters don’t reach in 65% of cases

Can J Surg. 2010 Jun;53(3):184-8.

Prehosp Emerg Care. 2009 Jan-Mar;13(1):14-7

J Trauma. 2008 Jan;64(1):111-4

J Trauma 2008 Oct;65(4)”:964

Accid Emerg Med 1996;6:426–7

Injury 1996;5:321–2.

• Finger Thoracostomy ▫ Indications

Any pneumothorax in a patient undergoing positive pressure ventilation

Actual or near traumatic cardiac arrest

Shocked state with no apparent cause

Early Trauma Care • Finger Thoracostomy

▫ Advantages The lung can be felt / seen to re-expand

If the patient persists in a shocked state during transport, the thoracostomy can be “re-fingered” to ensure the lung is up, thus excluding one cause of obstructive shock

Avoids intubation of the chest in a non-clinical area

Avoids risk of re-tension caused by blockage and kinking of drainage systems

▫ Disadvantages Invasive

Risk of thoracostomies becoming occluded by patient’s arms when packaged

▫ Fitzgerald M, Mackenzie CF, Marasco S, Hoyle R, Kossmann T. Pleural decompression and drainage during trauma reception and resuscitation. Injury. 2008 Jan;39(1):9-20. doi: 10.1016/j.injury.2007.07.021. Review. PubMed PMID: 18164300

Early Trauma Care

• CT scanning Pan Scan Vs Selective Imaging

▫ Lower mortality in “pan scan” Vs selective

▫ Shorter emergency times

▫ Pan scan

Higher MOF and mechanical ventilation days

LOS not different

Early Trauma Care • CT scanning Pan Scan Vs Selective Imaging

▫ Initial Imaging strategies of Trauma Patients at Victoria's Two Major Adult

Trauma Centres Surenda, AMS 2014

▫ Results

hospital A more selective CT scanning ▫ 3x more likely to require additional imaging

▫ Ending up same total scans as hospital B at 24hrs ▫ Concerns re radiation dosages and trips to radiology and cost

hospital B more whole body ▫ more guideline approach to care , 2x odd of receiving WBCT ▫ 4x patients went home or to SSU in first 24hrs


• CT scanning

▫ Blunt abdominal trauma

6% of all major injuries

Early in 20th century abdominal trauma high mortality and low threshold for laparotomy

CT scanning resulted

Change to non-operative management decisions

Availability of CT scanners and intro of embolisation

▫ Reduced mortality

Early Trauma

• Focused Assessment Sonograph Trauma (FAST)

▫ Change methods of diagnosing blunt abdominal trauma

Refine decision making & enable cx management

Also used for diagnosis of

Pericardial tamponade and pneumothorax

Surgical Intervention

ED Thoracotomy Guidelines

• Penetrating Trauma Indication

▫ < 5mins CPR on arrival

▫ Patient in extremis on arrival to ED

▫ Witnessed cardiac arrest in ED

• Blunt Trauma Indication

▫ Witnessed cardiac arrest in the ED

Penetrating Chest Trauma Extremis (BP <60 not responding to fluid resusitation)

and/ or CPR < 10 mins with signs of life

Signs of Life Pupil response

Respiratory effortCardiac activity

Spontaneous Movement Palpable pulse

Cessation of treatment

Downgrade Trauma OPSTAT

Notify theatre # 6312 or 6311

Call Cardiothoracics

and

Perform an EDT

Return of

SOL URGENT THEATRE

Aims of EDT Release tamponade

Control haemorrhageControl air embolism

Open cardiac massageCross clamp aorta

Patient arrives in extremis with blunt

or penetrating chest trauma Primary/ Secondary Survey

No

Blunt Torso Trauma Witness Cardiac Arrest

Signs of

life

Yes

No

No

Cessation of EDT Irreparable damage

Unsurvivable head injuriesPulseless electrical activity

Systolic <70 after 15-20 minsAsystolic arrest

Patient Requires Urgent

Thoracotomy

Call cardiothoracics

No

Emergency Department Thoracotomy

Yes

Yes

If patient is expected with penetrating/ blunt chest trauma in extremis notify cardiothoracic team

TRAUMA OPSTAT

Yes

No

Yes

Yes

Operative Guidelines Damage control

Laparotomy < 1 hr duration

Stop bleeding

Clamps/ packs

Stem contamination

Staple

Drain/ removal of septic focus

Laparostomy/ dressing

Trauma Resuscitation • Pregnancy

▫ Look after the mother look after the fetus

• Radiation

▫ The fear of cancer risk from CT scans should never influence he appropriate radiologic evolution of the trauma patient

▫ CT scanning has never been shown to cause cancer but has saved many lives with it proper and appropriate use

Thank you

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