TraumaTrauma andand CriticalCritical CareCare ResuscitationResuscitation

Byron Turkett, PA-C MPAS Division of Trauma/Critical Care Department of Surgery University of Tennessee Medical Center Knoxville, TN UniversityUniversity ofof TennesseeTennessee MedicalMedical CenterCenter -- KnoxvilleKnoxville UTMCUTMC--KK LevelLevel 11 TraumaTrauma CenterCenter

RegionalRegional TeachingTeaching HospitalHospital SurgerySurgery ResidencyResidency andand SurgicalSurgical CriticalCritical CareCare FellowshipFellowship 250250 milemile RadiusRadius LevelLevel 11 TraumaTrauma CenterCenter ServiceService AreaArea CoveringCovering 44 StatesStates 34253425 TraumaTrauma AdmissionsAdmissions 20042004 2424 BedBed DedicatedDedicated Trauma/NeuroTrauma/Neuro IntensiveIntensive CareCare UnitUnit 30%30% TraumaTrauma ICUICU AdmissionAdmission RateRate EpidemiologyEpidemiology

U.S.U.S. traumatrauma relatedrelated costscosts exceedexceed $400$400 billionbillion dollarsdollars annuallyannually MVCMVC’’ss accountaccount forfor 70%70% ofof traumatrauma morbiditymorbidity andand mortalitymortality LeadingLeading causecause ofof deathdeath inin personspersons agedaged 11 –– 4444 yearsyears 6060 millionmillion injuriesinjuries perper yearyear occursoccurs inin thethe U.S.U.S. – Results in an average of 36.8 million hospital visits per year (40% of all ED visits) EpidemiologyEpidemiology

InjuryInjury isis aa diseasedisease ItIt hashas aa ““hosthost”” andand ““vectorsvectors”” – The patient is the host – Vectors include cars, motorcycles, ATVs, PWCs, et al TheThe prevention,prevention, researchresearch andand treatmenttreatment ofof traumatrauma isis woefullywoefully underunder fundedfunded comparedcompared toto infectiousinfectious disease,disease, heartheart diseasedisease andand cancercancer TraumaTrauma continuescontinues toto affectaffect thethe mostmost productiveproductive membersmembers ofof societysociety andand particularlyparticularly ourour mostmost valuablevaluable nationalnational resource,resource, childrenchildren AA TypicalTypical DayDay inin thethe TraumaTrauma CenterCenter ItIt’’ss aa beautifulbeautiful dayday inin EastEast TennesseeTennessee YouYou havehave hadhad 22 cupscups ofof coffeecoffee YourYour onlyonly patientpatient isis justjust waitingwaiting onon aa floorfloor bed,bed, hashas aa PCA,PCA, foleyfoley andand feedsfeeds themselvesthemselves YourYour biggestbiggest decisiondecision soso farfar todaytoday isis…… …..”Do I want the sirloin or grilled salmon from STEAKOUT Delivery”….. Finally,Finally, aa nicenice QUIETQUIET dayday……andand thenthen itit startsstarts

TheThe TraumaTrauma SystemSystem && NotificationNotification

TheThe PagePage OutOut – Modified Alert Stable VS, not intubated – Arriving via LifeStar – ETA is 5 minutes – Today’s weather, 40 degrees/light rain LifeStarLifeStar’’ss RadioRadio CallCall – 34 y/o male – MVC URD, ejected, + LOC, L femur deformity, decreased BS on the left, no visible movement of the lower extremities, responded to a fluid challenge WhatWhat areare youyou thinkingthinking aboutabout possiblepossible injuries?injuries? ThinkThink headhead toto toetoe ThinkThink worseworse casecase scenarioscenario andand workwork backwardsbackwards MaintainMaintain aa highhigh indexindex ofof suspicionsuspicion NeverNever assumeassume anything!anything! WhatWhat diddid LifeStarLifeStar See?See? TheThe TraumaTrauma AssessmentAssessment

GettingGetting thethe TraumaTrauma BayBay ReadyReady – Staff at the bedside Trauma Response Team (Attending, Resident, PA/NP, 2 RN’s) X-ray, Lab, Respiratory Therapy – Necessary Equipment Airway Box/Ventilator/Oxygen Pre-assembled IVF’s Level 1 Infuser Monitor/Manual BP cuff Medications “The Trauma Head – MD/MLP Team Leader, examines head to chest, Team” Manages ABC’s

Diagram Lead Trauma RN Assessment, Vitals, IV Access, Assist Team Leader, Documentation

Trauma Assist RN/Paramedic Right 1 – MD/MLP IV access, operate Level 1 FAST U/S, upper extremity, infuser, blood products, meds soine & abdomen exam, chest tube

Left 1 – MD/MLP Right 2 – MD/MLP Extremity exam, chest tube, Femoral access/blood, rectal, admit H&P foley, lower extremity exam

Out of the box: X-ray, lab, security, chaplain, unit secretary, patient Attending Trauma Surgeon representative, Supervises all activities bystanders TheThe TraumaTrauma AssessmentAssessment TheThe TraumaTrauma AssessmentAssessment

PrimaryPrimary AssessmentAssessment AAirwayirway –– Clear,Clear, talkingtalking AirwayAirway AirwayAirway AirwayAirway AirwayAirway AirwayAirway TheThe TraumaTrauma AssessmentAssessment

PrimaryPrimary AssessmentAssessment BBreathingreathing – Absent breath sounds on left – Rate >40/min, Pulse Ox 85% CCirculationirculation – HR 110 thready, SBP 100, distal pulses 1+ – No obvious bleeding, left thigh is swollen/firm – IV Access Minimum (2) 14 gauge sites or Central High Flow Line Use Warmed LR TheThe TraumaTrauma AssessmentAssessment

PrimaryPrimary AssessmentAssessment DDisablityisablity –– BriefBrief NeurologicNeurologic AssessmentAssessment GCS is 13 (confused, sleepy) Weak upper and no lower extremity movement Pupils are 4mm, equal, reactive EExposurexposure –– CompletelyCompletely UndressUndress –– WarmWarm blanketsblankets toto preventprevent hypothermiahypothermia TraumaTrauma AssessmentAssessment

AdjunctsAdjuncts toto thethe PrimaryPrimary SurveySurvey Obtain ABG – Ph 7.25, PCO2 50, PO2 64, O2 Sat 90%, HCO3 17, Base -7 Attach Cardiac Monitor – Sinus Tach Order initial labs and x-rays – CBC, UA, T & C, Coags, CXR, Trauma CT Scan, L femur xray Perform FAST U/S Reassess ABC’s – Airway clear – Breathing - more labored and shallow, O2 sat 89% on NRB – Circulation - HR120, SBP 95 (after 2 L fluid bolus) TraumaTrauma AssessmentAssessment

SecondarySecondary SurveySurvey && ManagementManagement FFingeringer andand TubeTube inin everyevery holehole && FFliplip –– FoleFoley,y, NG,NG, RectalRectal GGiveive painpain andand sedationsedation medicationsmedications asas neededneeded HHeadead toto ToeToe ExaminationExamination HHistoryistory –– PMH/PSH,PMH/PSH, meds/allergiesmeds/allergies IInterventionsnterventions ChestChest XX--raysrays ChestChest TubeTube ((ThoracostomyThoracostomy)) WhatWhat happenshappens ifif youyou forgetforget youryour ABCABC’’s?s? TraumaTrauma AssessmentAssessment

PhysicalPhysical ExamExam findingsfindings – Posterior C-spine tenderness – Decreasing level of consciousness (GCS 8) – Seat belt sign over chest and abdomen – Bilateral breath sounds after the chest tube – Abdomen is distended and without tenderness, no rectal tone – Deformed mid thigh, cool to touch, delayed cap refill – Left DP/PT barely palpable – Minimal upper extremity flexion, flaccid lower extremities TraumaTrauma AssessmentAssessment

YourYour lablab resultsresults andand XX--RaysRays – H/H 6.9/20; UA trace blood; INR 2.5 – FAST Exam showed splenic renal interface and pelvic free fluid – 2nd ABG – pH 7.19, pCO2 53, pO2 85, HCO3 15, Base -9 VitalVital signssigns afterafter thethe secondarysecondary surveysurvey – HR 130, SBP 80 (after 4L LR), O2 Sat 96% – RR more rapid and shallow, struggling on NRB WithoutWithout A,A, therethere isis nono B,B, WithoutWithout B,B, therethere isis nono CC ConstantlyConstantly recheckrecheck youryour ABCABC’’ss ThisThis patientpatient isis onon thethe vergeverge respiratoryrespiratory arrestarrest duedue to:to: – Chest trauma, pneumothorax – Increased work of breathing due to C-spine injury and subsequent diaphragm paralysis RapidRapid SequenceSequence IntubationIntubation – Analgesia – Morphine or Fentanyl – Sedation – Versed or Etomidate – Paralyzing Agent – Succinylcholine or Vecuronium CTCT ScanScan andand XX--RaysRays CTCT ScanScan CTCT ScanScan andand XX--RaysRays IdentifyingIdentifying InjuryInjury

LetLet’’ss listlist thethe injuriesinjuries –– ClosedClosed headhead injuryinjury w/decreasingw/decreasing GCSGCS –– CC--spinespine injuryinjury w/quadraplegiaw/quadraplegia –– LeftLeft PneumothoraxPneumothorax –– GradeGrade 22 spleenspleen lacerationlaceration –– LeftLeft femurfemur fracturefracture –– HemodynamicHemodynamic InstabilityInstability StabilizationStabilization andand DefinitiveDefinitive TreatmentTreatment CallCall thethe OROR NotifyNotify orthopedicorthopedic && neurosurgeonneurosurgeon GiveGive fluids/bloodfluids/blood productsproducts throughthrough thethe highhigh flowflow lineline – Continue LR – PRBC’s, FFP, Platelets ContinueContinue toto warmwarm toto >97>97 degreesdegrees TransferTransfer thethe patientpatient toto thethe OROR forfor definitivedefinitive hemostasishemostasis – Exploratory Laparotomy – Left Femur ORIF WhatWhat diddid thethe surgeonssurgeons find?find?

2L blood in abdomen Splenectomy performed No other intraabdominal injuries 1L blood loss from femur intramedullary nail Received 8u PRBC’s, 8u FFP and 10,000cc crystalloid YourYour patientpatient arrivesarrives inin thethe SurgicalSurgical CriticalCritical CareCare UnitUnit AbdomenAbdomen isis openopen andand vacvac packedpacked HRHR 125,125, SBPSBP 8282 OnOn fullfull VentVent SupportSupport EndEnd ofof casecase HCTHCT 2121 PatientPatient isis startingstarting toto emergeemerge fromfrom anesthesiaanesthesia CriticalCritical CareCare UnitUnit AssessmentAssessment

TheThe CriticalCritical CareCare UnitUnit TeamTeam – MD/MLP – RN – Respiratory Therapist – Pharmacist ReviewReview eventsevents && treatmenttreatment toto thisthis pointpoint OrderOrder newnew labs/chestlabs/chest xx--rayray – CBC, BMP, ABG, COAGS, CXR TertiaryTertiary ExamExam (Head(Head toto toe)toe) LookLook forfor undiscoveredundiscovered injuriesinjuries EstablishEstablish CareCare && TreatmentTreatment PlansPlans forfor 2424 hourshours CriticalCritical CareCare UnitUnit AssessmentAssessment

ContinueContinue thethe resuscitationresuscitation –– EndpointsEndpoints include:include: UOP > 30cc (0.5cc/kg/hr) Base Deficit < 3 Stabilized HCT and SBP without pressor support SedationSedation && AnalgesiaAnalgesia –– Narcotics,Narcotics, PRNPRN && DripsDrips Fentanyl, Morphine –– AmnesicsAmnesics && AnxiolyticsAnxiolytics Versed, Ativan, Propofol CriticalCritical CareCare UnitUnit AssessmentAssessment

CommunicateCommunicate withwith youryour secondarysecondary patientpatient –– HaveHave thethe MD/MLPMD/MLP presentpresent ifif possiblepossible –– GiveGive thethe familyfamily aa briefbrief ““whatwhat toto expectexpect”” summarysummary beforebefore theythey reachreach thethe bedsidebedside –– IdentifyIdentify thethe nextnext ofof kin/decisionkin/decision makermaker –– ““SpeakSpeak thethe locallocal languagelanguage”” –– ItIt’’ss o.k.o.k. toto carecare CriticalCritical CareCare UnitUnit AssessmentAssessment

PreventivePreventive MeasuresMeasures –– DVTDVT ProphylaxisProphylaxis PAS Lovenox, heparin, IVC filter Ambulation –– PUDPUD ProphylaxisProphylaxis Diet Enteral Feeding H2 blockers & Proton Pump Inhibitors CriticalCritical CareCare UnitUnit AssessmentAssessment

VentilatorVentilator AssociatedAssociated PneumoniaPneumonia BundleBundle –– HOBHOB atat 3030 degreesdegrees –– OralOral CareCare –– DVTDVT && PUDPUD prophylaxisprophylaxis PatientPatient PositioningPositioning –– RepositionReposition everyevery 22 hourshours –– UtilizeUtilize SkinSkin ProtectionProtection BedBed SystemsSystems KinAire, RotaRest TheThe PhysiologicPhysiologic EffectsEffects ofof TraumaTrauma CHI/SAH/IPHCHI/SAH/IPH Central Nervous System Gastrointestinal – Sensory/Motor/cognitive – Increased incidence of deficits PUD – Loss of basic reflexes Coagulation Cardiovascular – Increased bleeding and – Arrythmias elevated INR Respiratory Acid Base – Impaired respiratory drive – Impaired respiratory and perfusion causes acidosis Renal Common Complications – Electrolyte disorders Common Complications – Increased ICP, herniation, – Large volume diuresis – Increased ICP, herniation, brain death TheThe PhysiologicPhysiologic EffectsEffects ofof TraumaTrauma SpinalSpinal CordCord InjuryInjury Cardiovascular Gastrointestinal – Loss of sympathetic vascular – Inability to self feed, requiring tone enteral feeding – Hypotension – Hypoalbuminemia, – Bradyarrythmias malnutrition Respiratory Coagulation – Loss of innervation to – High risk for DVT/PE diaphragm, abdominal and – Requires IVC filter intercostals Common Complications – Increased pCO2, work of – Muscle wasting syndrome breathing – Skin breakdown/decubitus – Prolonged vent support and possible tracheostomy – Infection Renal – Hypotension causes hypoperfusion and ARF – Incontinence/Catheterization TheThe PhysiologicPhysiologic EffectsEffects ofof TraumaTrauma ChestChest Trauma/Trauma/PneumothoraxPneumothorax Central Nervous System Renal – Altered MS due to elevated – Compensates for elevated pCO2 pCO2, holds on to HCO3 Cardiovascular Common Complications – Hypoxemia – Atelectasis – Impaired function with – Respiratory failure tension PTX – Empyema Respiratory – ARDS – Decreased pO2, elevated – VAP pCO2 – Increased work of breathing – Elevated Airway pressures – Altered tissue perfusion TheThe PhysiologicPhysiologic EffectsEffects ofof TraumaTrauma SpleenSpleen LacerationLaceration Central Nervous System Coagulation – Shunting preserves function until – Large volume blood loss leads to late stage consumptive coagulopathy and Cardiovascular further hemorrhage – Hypotension Acid-Base – Hyperdynamic cardiac function – Blood loss leads to anaerobic metabolism – Decreased tissue perfusion metabolism – Build up of lactic acid and Respiratory increased base deficit – Compensatory increased Common Complications respiratory rate Common Complications – High risk for encapsulated Renal bacterial infections – Hypoperfusion causes ARF/CRF – At risk for OPSS (Overwhelming (elevated BUN/Cr) Post Splenectomy Sepsis) Gastrointestinal – Must give H. flflu,u, Meningococcal & – Decreased gastric pH and S. Pneumo vaccines increased risk for PUD – NPO period can cause malnutrition/failure to heal TheThe PhysiologicPhysiologic EffectsEffects ofof TraumaTrauma FemurFemur FractureFracture CentralCentral NervousNervous SystemSystem – Alerted MS, seizure coma due to fat emboli CardiovascularCardiovascular – Tachycardia, hypotension due to blood loss – Blood loss can be 1-2L in the thigh – Possible arterial occlusion around fracture site RespiratoryRespiratory – Fat Emboli Syndrome Inflammatory and obstructive mechanism – High risk for DVT, PE TheThe PhysiologicPhysiologic EffectsEffects ofof TraumaTrauma HypothermiaHypothermia CentralCentral NervousNervous SystemSystem – CNS depression CardiovascularCardiovascular – Bradycardia (not vagal mediated) – Hypotension CoagulationCoagulation – Increased bleeding due to cold related factor dysfunction AcidAcid –– BaseBase – Worsening acidosis QuestionsQuestions oror Comments?Comments? ContactContact InformationInformation

ByronByron Turkett,Turkett, PAPA--C,C, MPASMPAS [email protected]