Major Trauma Management and Trauma Team Roles
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Major Trauma Management and Trauma Team Roles
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Major Trauma Management and Trauma Team Roles
- 1. Major Trauma Management and Trauma Team Roles Dr Christopher Moseley CME Teaching 8th September 2016
- 2. Objectives • Definition • State Trauma Network • Trauma Calls • Team Roles • Trauma mindset • Major Hemorrhage Protocol
- 3. Trauma Definition • A term derived from the Greek for “WOUND” • It refers to bodily injury. • It defined as tissue injury due to direct effects of externally applied energy. Energy may be mechanical, thermal, electrical, electromagnetic or nuclear. • Includes: burns, drowning, smoke, inhalation and fall. • Excludes: poisoning/toxic ingestion.
- 4. Trauma Definition Major trauma — ‘multiple trauma’ — refers to major injury affecting more than one body system. It can also be defined as an Injury Severity score > 15.
- 5. Trauma in Australia Trauma accounts for: • 7.5% of total deaths • 5.5% of hospitalisations • 7% of the total burden of disease in Australia * (Australian Institute of Health and Welfare, 2008).
- 10. WA Trauma NetworkTrauma at Charles
- 14. WA Trauma Network TRIMODAL DISTRIBUTION OF TRAUMA DEATHS. First Peak – Seconds to minutes (50% all deaths) Second Peak – Minutes to hours. This is why we do what we do as this is where we save lives Third Peak – Days to weeks
- 15. Major Trauma Code 10 minutes
- 16. What now? Preparation, triage and activation of the trauma resuscitation team
- 17. Recognize your in it!
- 19. People 1) Clear roles and organization 2) Effective communication 3) Support from other hospital areas, transfer services and trauma centres
- 21. Trauma Definition • A term derived from the Greek for “WOUND” • It refers to any bodily injury. • It defined as tissue injury due to direct effects of externally applied energy. Energy may be mechanical, thermal, electrical, electromagnetic or nuclear. • Included:burns, drowning, smoke, inhalation and fall. • Excluded: poisoning/toxic ingestion.
- 24. Drugs and Equipment Consider what may be required prior to arrival: • Difficult airway trolley • Blood including rapid transfuser • Drugs – e.g analgesia, TXA • IO kit • Procedure kits – chest tubes/thoracotomy kit *USS machine in the bay ready to go
- 25. Specialties Specialties may include orthopedics, neurosurgery, cardiothoracics, plastics, ENT and ophthalmology. Early notification of operating theatre staff and ICU is also crucial for critically ill trauma patients. Radiography and radiology staff are a key part of trauma team activation.
- 28. https://i.ytimg.com/vi/TQLtISfDxcc/maxresdefault.jpg http://emcrit.org/wee/real-surgical-airway/
- 29. HAEMOSTATIC RESUSITATION In the bleeding trauma patient if it doesn’t carry oxygen or it doesn’t clot then use with caution
- 30. 1 in 4 trauma patients bleed abnormally The phenomenon of an early coagulopathy in trauma – which goes by many names, including the Acute Coagulopathy of Trauma-Shock (ACoTS) – can occur soon after injury, and is physiologically distinct from the DIC-like phenomenon associated with the “lethal triad” Trauma patients bleed abnormally
- 32. Hypothermia Decreases platelet responsiveness, increases platelet sequestration in liver and spleen, reduces Factor function eg Factors XI and XII. Alters fibrinolysis Acidosis pH strongly effects activity of Factors V, VIIa and X. Acidosis inhibits thrombin generation. Cardiovascular effects of acidosis (pH <7.2) – decreased contractility and CO, vasodilatation and hypotension, bradycardia and increased dysrhythmias Lethal Triad
- 34. • Give blood products instead of isotonic crystalloid fluid aiming for limited volume replacement. • Large volume crystalloids can lead to dilutional coagulopathy and exacerbate bleeding. • Crystalloids have no O2 carrying capacity and do little to correct the anaerobic metabolism and O2 debt associated with shock. • Oedema, compartment syndrome, resp distress Blood Vs Crystalloid
- 35. Provides resuscitation with blood components resembling whole blood with the aims of: • maintain circulating volume • limit ongoing bleeding • prevent the lethal trial of hypothermia, acidosis and acute coagulopathy of trauma Typical triggers are: • expected or actual haemorrhagic shock • 4 PRBCs administered and instability persists Haemostatic Resusitation
- 36. • Involves blood component ratios of 1 or 2 RBCs : 1 FFP : 1 platelets • Rick Dutton freely admits that he made up the ratio of 1:1:1 based in the rationale that it mimics the composition of whole blood • Australian National Guidelines advocates 2:1:1 ratio HOW?
- 37. • There is no RCT evidence for RBC:FFP:platelet ratios of 1-2:1:1 versus other ratios/ fluids • The PROPPR trial (2015) found no statistically significant mortality difference on the primary outcome of mortality between massive transfusion protocols based on 1:1:1 and 2:1:1 ratios. There was an absolute difference in mortality of about 4% favouring the 1:1:1 ratio Evidence
- 38. • Other agents may be given based on blood tests: • INR >1.5 – FFP • Hb <100 in an actively bleeding -> PRBCs • Calcium <0.8 - calclium gluconate • Platelets <80 - platelets • platelet dysfunction (e.g. drugs) - platelets Adjuncts
- 39. Tranexamic Acid Tranexamic acid (TXA) is an anti-fibrinolytic agent that can/should be used early in the resuscitation of bleeding trauma patients The effect of TXA on mortality in bleeding trauma patients is very time-dependent, conferring a huge survival advantage if given early
- 40. Tranexaminc Acid Tranexamic acid (TXA) use is supported by the CRASH2 trial: • a multicenter international RCT • Mortality benefit if given to major trauma patients within 3 hours of injury.
- 41. Cryoprecipitate • Fibrinogen is the primary substrate for clot formation (along with platelets) • There is a consistent link between falling fibrinogen and mortality in trauma • The key is to measure and follow serum fibrinogen in bleeding patients – a fibrinogen less than 1.0 g/L identifies a hypofibrinogenemic state, the antidote for which is cryoprecipitate.
- 44. Management of Major Trauma, Team roles …and stuff… This Is the sum total of my knowledge on the subject so questions to the boss!
Hinweis der Redaktion
- And while much of the damage from head injury is spoken for at the time of accident, the initial resuscitation of a bleeding trauma patient can have a tremendous impact on survival. To be clear, the most important step in managing these patients is surgical source control – most patients with massive hemorrhage need an operation to stay the hemorrhage. The state in which a patient arrives to the operating room or the intensive care unit – alive or near death, cold and coagulopathic or warm and well perfused – is up to you.
- And while much of the damage from head injury is spoken for at the time of accident, the initial resuscitation of a bleeding trauma patient can have a tremendous impact on survival. To be clear, the most important step in managing these patients is surgical source control – most patients with massive hemorrhage need an operation to stay the hemorrhage. The state in which a patient arrives to the operating room or the intensive care unit – alive or near death, cold and coagulopathic or warm and well perfused – is up to you.
- TRIMODAL DISTRIBUTION OF TRAUMA DEATHS. THE FIRST PEAK OF DEATHS OCCURS WITHIN FEW SECONDS TO MINUTES AFTER INJURY(50% OF ALL DEATHS). Virtually inevitable & very little can be done. THE SECOND PEAK OCCURS BETWEEN A FEW MINUTES AND AN HOUR AFTER INJURY. Can be reduced by prompt initial care in the pre-hospital phase,by early hospital resuscitation and by prompt and competent definitive care.This period has been labelled as “THE GOLDEN HOUR”. Management at this time will affect the third peak of deaths. THE THIRD PEAK OCCURS SEVERAL DAYS OR WEEKS AFTER THE INITIAL INJURY.
- FIRST THING – recognize it’s a trauma code and not a medical code so don’t start ALS as its bullshit. one person on AIRWAY 2) two people in fingure thorocstomy – bilateral, fingure in and sweep around. Why – massive pneumothorax and its treated, haemothorax and its drained. USS - ? pericardial tamponade – If 2 and 3 show nothing then stop!!! Adenaline may get the heart pumping but you aint getting the brain back – you don’t want that!
- Team structures vary between systems and hospitals. In small centres the team may consist of only a doctor and a nurse. In trauma centres there are defined roles, and the team members assemble when activated by a trauma call. More important than the composition of the trauma team is that the team members are trained in the emergency care of trauma patients and work effectively as a team with:
- And while much of the damage from head injury is spoken for at the time of accident, the initial resuscitation of a bleeding trauma patient can have a tremendous impact on survival. To be clear, the most important step in managing these patients is surgical source control – most patients with massive hemorrhage need an operation to stay the hemorrhage. The state in which a patient arrives to the operating room or the intensive care unit – alive or near death, cold and coagulopathic or warm and well perfused – is up to you.
- And while much of the damage from head injury is spoken for at the time of accident, the initial resuscitation of a bleeding trauma patient can have a tremendous impact on survival. To be clear, the most important step in managing these patients is surgical source control – most patients with massive hemorrhage need an operation to stay the hemorrhage. The state in which a patient arrives to the operating room or the intensive care unit – alive or near death, cold and coagulopathic or warm and well perfused – is up to you.
- In addition to the trauma/ general surgical doctor, other surgical specialties may be alerted to the trauma call as the scenario demands. These specialties may include orthopedics, neurosurgery, cardiothoracics, plastics, ENT and ophthalmology. Early notification of operating theatre staff and ICU is also crucial for critically ill trauma patients. Notification of radiography and radiology staff is also a key part of trauma team activation. This ensures rapid access to diagnostic +/- interventional radiology and allows rapid decision making. In some centres the composition of the team depends on the level of the trauma call activation. For instance, a trauma call based on mechanism may activate an ED only call, whereas a patient with deranged physiological parameters may activate a ‘full’ trauma call.
- DAMAGE CONTROL RESUSCITATION Damage control resuscitation (DCR) is a systematic approach to the management of the trauma patient with severe injuries that starts in the emergency room and continues through the operating room and the intensive care unit (ICU)DCR involves haemostatic resuscitation, permissive hypotension (where appropriate) and damage control surgeryDCR aims to maintain circulating volume, control haemorrhage and correct the ‘lethal triad’ of coagulopathy, acidosis and hypothermia until definitive intervention is appropriate
- J Surg Educ. 2015 Jul-Aug;72(4):732-9. doi: 10.1016/j.jsurg.2015.01.020. Epub 2015 Mar 26. The role of nontechnical skills in simulated trauma resuscitation. OBJECTIVE: Trauma team training provides instruction on crisis management through debriefing and discussion of teamwork and leadership skills during simulated trauma scenarios. The effects of team leader's nontechnical skills (NTSs) on technical performance have not been thoroughly studied. We hypothesized that team's and team leader's NTSs correlate with technical performance of clinical tasks. DESIGN: Retrospective cohort study. SETTING: Brigham and Women's Hospital, STRATUS Center for Surgical Simulation PARTICIPANTS: A total of 20 teams composed of surgical residents, emergency medicine residents, emergency department nurses, and emergency services assistants underwent 2 separate, high-fidelity, simulated trauma scenarios. Each trauma scenario was recorded on video for analysis and divided into 4 consecutive sections. For each section, 2 raters used the Non-Technical Skills for Surgeons framework to assess NTSs of the team. To evaluate the entire team's NTS, 2 additional raters used the Modified Non-Technical Skills Scale for Trauma system. Clinical performance measures including adherence to guidelines and time to perform critical tasks were measured independently. RESULTS: NTSs performance by both teams and team leaders in all NTS categories decreased from the beginning to the end of the scenario (all p < 0.05). There was significant correlation between team's and team leader's cognitive skills and critical task performance, with correlation coefficients between 0.351 and 0.478 (p < 0.05). The NTS performance of the team leader highly correlated with that of the entire team, with correlation coefficients between 0.602 and 0.785 (p < 0.001). CONCLUSIONS: The NTSs of trauma teams and team leaders deteriorate as clinical scenarios progress, and the performance of team leaders and teams is highly correlated. Cognitive NTS scores correlate with critical task performance. Increased attention to NTSs during trauma team training may lead to sustained performance throughout trauma scenarios. Decision making and situation awareness skills are critical for both team leaders and teams and should be specifically addressed to improve performance.
- Haemostatic resuscitation is a key component of damage control resuscitation and forms the basis of most massive transfusion protocols. It involves resuscitation with blood components resembling whole blood aims to avoid or ameliorate acute coagulopathy of trauma and the complications of aggressive crystalloid fluid resuscitation while maintaining circulating volume. damage control resuscitation is an approach to major trauma that integrates permissive hypotension, haemostatic resuscitation and damage control surgery
- Bleeding causes acidosis, hypothermia, and coagulopathy. Then the cycle begins as they all beget each other. If this continues for too long, it is irreversible.
- Now we know why we do it, whats the aim and hom?
- 500mls – HC 38-50 plt 150-400 Add 150ml anticoagulant Patient recieves 650 mls back – Hct 29plt 88, clotting 60
- The PROPPR trial (2015) found no statistically significant mortality difference on the primary outcome of mortality between massive transfusion protocols based on 1:1:1 and 2:1:1 ratios. There was an absolute difference in mortality of about 4% favouring the 1:1:1 ratio, but the study was not powered to detect this. A post-hoc secondary outcome of death by exsanguination in the first 24 hours also favoured the 1:1:1 ratio. The trial was a pragmatic unblinded outcome and neither arm of the trial managed to achieve the intended blood product ratios, though there was clear separation between the 2 groups.
- In a massively bleeding patient, fibrinogen can drop to clinically important levels faster than other blood components, and its breakdown and synthesis are affected by hypothermia and acidosis — leading to a vicious cycle of abnormal clot formation and excessive bleeding (Figure 10).