DOCSLIB.ORG

Chapter 1 Physiology of Injury and Early Management of Combat Casualties

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Chapter 1 Physiology of Injury and Early Management of Combat Casualties Physiology of Injury and Early Management of Combat Casualties Chapter 1 PHYSIOLOGY OF INJURY AND EARLY MANAGEMENT OF COMBAT CASUALTIES † ‡ DIEGO VICENTE, MD*; BENJAMIN K. POTTER, MD ; AND ALEXANDER Stojadinovic INTRODUCTION GOLDEN HOUR MANAGEMENT OF COMBAT CASUALTIES AT ROLE 2 AND 3 FACILITIES CARDIOVASCULAR INJURY PULMONARY INJURY NEUROLOGIC INJURY RENAL INJURY HEPATIC INJURY HEMATOLOGIC INJURY ANESTHESIA SUMMARY *Lieutenant, Medical Corps, US Navy; Department of General Surgery; Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, Maryland 20889-5600 †Major, Medical Corps, US Army; Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, Maryland 20889-5600 ‡Colonel, Medical Corps, US Army, Department of General Surgery, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, Maryland 20889-5600 3 Combat Anesthesia: The First 24 Hours INTRODUCTION The recent conflicts in Iraq and Afghanistan have initiation of emergency medical care in accordance resulted in a marked change in both the injury patterns with Tactical Combat Casualty Care (TCCC) guidelines sustained by wounded personnel and the subsequent in proximity to point of wounding,2,3 tactical damage management of these injuries. Survival of combat control surgery and resuscitation, and rapid transport casualties (CCs) despite severe polytrauma is largely to escalating levels of care with “critical care in the air” attributable to improvements in body armor,1 prompt intensive monitoring and care capability. GOLDEN HOUR Improvised explosive devices (IED) have been the blasts23 exposes the CC not only to the immediate most common mechanism of CC injury in these con- threat of hemorrhagic, obstructive, cardiogenic, and flicts.4–9 Troops in mine-resistant ambush-protected neurogenic shock, but also to a severe posttraumatic (MRAP) vehicles involved in IED blasts are well-pro- inflammatory response,24,25 which can lead to trau- tected, and injuries are usually limited to lower extrem- matic shock.26,27 The extent of injuries and time to ity and axial skeleton-loading fractures.10 However, the medical care dictate the magnitude of shock,28 as most severe blast injuries are endured by troops on foot measured by oxygen debt, which correlates signifi- patrol who are involved in dismounted IED blasts in cantly with the risk of mortality.29–31 Furthermore, the which they are exposed to primary, secondary, tertiary, magnitude of shock is also closely associated with a and quaternary blast trauma.11 Modern advancements potentially overwhelming immune response, which in body armor worn by troops (including Kevlar [Du- can cause acute respiratory distress syndrome (ARDS) Pont, Wilmington, DE] helmets and Kevlar vests with and multiple organ dysfunction syndrome.32–36 This ceramic plates) have improved survival by decreas- cascade of physiologic events illustrates the impor- ing secondary blast injuries to the head and thorax. tance of minimizing time to medical intervention Despite widespread use of body armor, dismounted as defined by the principle of the “golden hour” of troops involved in IED blasts can still suffer traumatic trauma. This time is vital to the care of trauma vic- brain injury (TBI), as well as burns, soft tissue injury, tims and is embodied in the prehospital principles fractures, and neurovascular damage to the pelvis, of military trauma care by first responders in TCCC perineum, and extremities.5,8,9,12,13 These insults mani- as well as rapid transfer to higher levels of surgical fest clinically as mangled or amputated appendages, and resuscitative care. altered mental status, pain, cardiovascular collapse, respiratory failure, loss of airway, visceral injury, and Tactical Combat Casualty Care acute hemorrhage. The severe blood loss associated with blast injuries TCCC is initiated at the time of the blast and is decreases oxygen delivery, and the CC enters a state implemented during care under fire, through tactical of physiological shock in which the supply of oxygen field care, and finally during tactical evacuation care fails to meet the demand of the tissues, resulting in (Figure 1-2). 3 The emergent needs for the CC include end-organ dysfunction. The body promptly responds airway and ventilation maintenance, hemorrhage to the hemorrhage by inducing intense vasocon- control with rapid application of tourniquets37–39 and striction to shunt blood centrally to the heart and brain.14,15 Decreased perfusion to the peripheral tis- sues induces anaerobic respiration, which produces lactic acid, ultimately leading to metabolic acidosis. Hypothermia Metabolic acidosis, in turn, alters the function of multiple critical enzymes16–18 and leads to coagu- lopathy.19 The state of shock, coupled with exposure to the elements, can induce hypothermia, thereby further exacerbating the coagulopathy, which leads to continued hemorrhage.20–22 The lethal triad (Figure 1-1) of acidosis, hypothermia, and coagulopathy Acidosis Coagulopathy becomes a vicious cycle, which, if uninterrupted, rapidly leads to death. The polytraumatic nature of the injuries from these Figure 1-1. Lethal triad. 4 Physiology of Injury and Early Management of Combat Casualties Care Under Fire Goals and Intervention - Move casualty to safety - Hemorrhage control with tourniquet(s) Goal Additional Available - Call for transport Interventions Maintain LMA Combitube Airway Endotracheal tube Goal Available Interventions Maintain Thoracostomy tube Recovery position Ventilation placement Maintain Chin lift Airway Nasopharyngeal airway Maintain Administer O2 by airway Surgical cricothyrotomy Oxygenation Also administer O2 for with casualties with TBI, altered Maintain Pneumothorax needle monitoring for mental status, or shock Ventilation Decompression goal >90% O2 Also for casualties at altitude Cover sucking chest wound saturation Reassess need for tourniquet, Hemorrhage Wound and tourniquet attempt to control bleeding Tactical Control Tactical reassessment with Combat Gauze Hemorrhage Field Evacuation Control Combat Ready Clamp Pneumatic anti-shock Care PO fluids for awake garment if suspected and alert patients pelvic fracture lV line lO line placement Resuscitation Hextend 500cc boluses for patients with altered MS Crystalloids blood products or with TBI and weak pulse Hypothermia (pRBC and FFP in 1:1 ratio) Prevention if in shock Hypothermia CPR if no HPMK* Prevention fatal wound identified Other Warm lV fluids Antibiotics for eye trauma and open wounds Analgesia Other Splint fractures Wound management Burn wounds coverage and burn resuscitation Figure 1-2. Tactical Combat Casualty Care (TCCC). As the combat casualty progresses through the stages of TCCC, he or she undergoes serial evaluations and repeated interventions as necessary. More resources and interventions are available at higher stages. cc: cubic centimeters; HPMK: Hypothermia Prevention/Management Kits (North American Rescue, Greer, SC; Part Number: 80-0027; NSN: 6515-01-532-8056.); LMA: laryngeal mask airway; O2: oxygen TBI: traumatic brain injury; FFP: fresh frozen plasma; pRBC: packed red blood cells; CPR: cardiopulmonary resuscitation; IV: intravenous Adapted from: Military Health System website. Tactical Combat Casualty Care Guidelines. August 8, 2011. http://www. health.mil/Education_And_Training/TCCC.aspx. Accessed September 26, 2012. hemostatic agents,40,41 judicious infusion of resuscita- Aeromedical Transport and Roles of Care tive fluids for CCs in shock with Hextend (BioTime, Inc, Berkeley, CA),42–46 and prevention of hypothermia. One of the most important advances in combat casu- These initial management steps—performed by self- alty care in these recent conflicts is prompt aeromedi- aid, buddy aid, and medics in austere environments— cal evacuation to higher roles of care (Figure 1-3). In a and the rapid transport to higher levels of care are combat theater, the severity of injuries and proximity designed to prevent progression to shock and mitigate to medical care determine which role of care the CC the effects of shock by improving oxygen delivery and will be taken to. Combat casualties sustaining major tissue perfusion. injuries will undergo casualty evacuation (CASEVAC) 5 Combat Anesthesia: The First 24 Hours Role Transport Time from Injury Role 1: Battle Aid Station (BAS)/Buddy and Self Aid Casualty Evacuation (CASEVAC) or 1 Hour Medical Evacuation (MEDEVAC) Role 2: Forward Surgical Team (FST) MEDEVAC with Critical Care Air Transport 24 - 48 Hours Role 3: Combat Support Team (CCAT) Hospital (CSH) MEDEVAC with CCAT 48 - 72 Hours Role 4: Landstuhl Regional Medical Center (LRMC) MEDEVAC with CCAT 96 - 120 Hours Role 4: Walter Reed National Military Medical Center (WRNMMC) Bethesda, San Antonio Military Medical Center (SAMMC) Figure 1-3. Roles of combat casualty care, transport, and time from injury. from the point of injury or battle aid station (BAS) she should be intubated and mechanically ventilated, to a forward surgical team (FST) within one hour. with a nasogastric or orogastric tube placed to prevent Combat casualties who suffer dismounted IED blasts aspiration during transport. All CCs on ventilator sup- likely require emergent surgical management,8 and port should have a recent arterial blood gas demon- hence should be transported to a Role 2 (FST) or Role strating adequate oxygenation and ventilation. If the 3 (combat support hospital [CSH]) facility in theater, CC is sedated, a presedation neurologic exam should
Load more

Recommended publications
  • Managing the Trauma Patient Presenting with the Lethal Trial
    PRACTICE DEVELOPMENT IN ORTHOPAEDICS AND TRAUMA Managing the trauma patient presenting with the lethal trial Nicola Credland University of Hull Practice development in orthopaedics and trauma It is essential that orthopaedic and trauma practitioners develop and maintain their own skills and knowledge in order to help improve and deliver quality care for patients. The utilisation of research in practice development is an important part of the process for nurses endeavouring to deliver evidence based practice to improve care and service user experience. This new series entitled 'Practice development in orthopaedics and trauma' aims to showcase initiatives and innovations in practice development that have transformed delivery of quality care around the world and to provide readers with brief summaries of current thinking in relation to clinical issues that are common features of orthopaedic and trauma nursing practice. The feature will provide readers with a summary of an evidence base with the aim of empowering them to initiate discussion with colleagues and question their own practice. There will be associated CPD activities incorporating self-directed learning that will enhance the series and provide nurses with an opportunity to extend their learning. The International Journal of Orthopaedic and Trauma Nursing invites contributions from clinical staff, educators and students normally of between 1000 and 2500 words. Items may focus on, but are not restricted to, best practice and practice development initiatives relating to clinical care issues, implementation of research findings and education and development of the workforce in the clinical environment. INTRODUCTION Musculoskeletal injury brings with it a pattern of physical trauma that can result in death in the hours, days and months that follow.
    [Show full text]
  • Fluid Resuscitation Therapy for Hemorrhagic Shock
    CLINICAL CARE Fluid Resuscitation Therapy for Hemorrhagic Shock Joseph R. Spaniol vides a review of the 4 types of shock, the 4 classes of Amanda R. Knight, BA hemorrhagic shock, and the latest research on resuscita- tive fluid. The 4 types of shock are categorized into dis- Jessica L. Zebley, MS, RN tributive, obstructive, cardiogenic, and hemorrhagic Dawn Anderson, MS, RN shock. Hemorrhagic shock has been categorized into 4 Janet D. Pierce, DSN, ARNP, CCRN classes, and based on these classes, appropriate treatment can be planned. Crystalloids, colloids, dopamine, and blood products are all considered resuscitative fluid treat- ment options. Each individual case requires various resus- ■ ABSTRACT citative actions with different fluids. Healthcare Hemorrhagic shock is a severe life-threatening emergency professionals who are knowledgeable of the information affecting all organ systems of the body by depriving tissue in this review would be better prepared for patients who of sufficient oxygen and nutrients by decreasing cardiac are admitted with hemorrhagic shock, thus providing output. This article is a short review of the different types optimal care. of shock, followed by information specifically referring to hemorrhagic shock. The American College of Surgeons ■ DISTRIBUTIVE SHOCK categorized shock into 4 classes: (1) distributive; (2) Distributive shock is composed of 3 separate categories obstructive; (3) cardiogenic; and (4) hemorrhagic. based on their clinical outcome. Distributive shock can be Similarly, the classes of hemorrhagic shock are grouped categorized into (1) septic; (2) anaphylactic; and (3) neu- by signs and symptoms, amount of blood loss, and the rogenic shock. type of fluid replacement. This updated review is helpful to trauma nurses in understanding the various clinical Septic shock aspects of shock and the current recommendations for In accordance with the American College of Chest fluid resuscitation therapy following hemorrhagic shock.
    [Show full text]
  • Prognostic Factors for Outcome and Survival After Laparotomy in Patients with Pancreatic Trauma: One Single-Center Experience
    Prognostic Factors for Outcome and Survival after Laparotomy in Patients with Pancreatic Trauma: One Single-center Experience. Chao Yang Jinling hospital Baochen Liu Jinling hospital Cuili Wu Jinling hospital Yongle Wang jinling hospital Kai Wang jinling hospital Weiqin Li Jinling hospital weiwei ding ( [email protected] ) Jinling hospital https://orcid.org/0000-0002-5026-689X Research Keywords: pancreatic trauma, prognosis, risk factor, logistic regression analysis Posted Date: April 9th, 2020 DOI: https://doi.org/10.21203/rs.3.rs-21555/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 1/13 Abstract Background: Pancreatic trauma results in signicant morbidity and mortality. Few studies have investigated the postoperative prognostic factors in patients with pancreatic trauma after surgery. Methods: A retrospective study was conducted on 152 consecutive patients with pancreatic trauma who underwent surgery in Jinling Hospital, a national referral trauma center in China, from January 2012 to December 2019. Univariate and binary logistic regression analyses were performed to identify the perioperative clinical parameters that may affect the morbidity of the patients. Results: A total of 184 patients with pancreatic trauma were admitted during the study period, and 32 patients with nonoperative management were excluded. The remaining 152 patients underwent laparotomy due to pancreatic trauma. Sixty-four patients were referred from other centers due to postoperative complications. Abdominal bleeding caused by pancreatic leakage ( 10 of all deaths) and severe intra-abdominal infection (12 of all deaths) were the major causes of mortality. Twenty-eight (77.8%) of the 36 patients who had damage control laparotomy survived.
    [Show full text]
  • When Trauma Means a Stoma
    10083-06_WJ3305-Steele.qxd 9/5/06 3:25 PM Page 491 J Wound Ostomy Continence Nurs. 2006;33(5):491-500. Published by Lippincott Williams & Wilkins O OSTOMY CARE When Trauma Means a Stoma Susan E. Steele Trauma is a leading cause of death and disability. When trau- injuries were sustained can assist the nurse in planning care matic injuries require ostomy surgery, the wound, ostomy, and and identifying the potential for complications during the continence nurse acts as a crucial part of the trauma team. This recovery period. Traumatic injuries occur when the human literature review describes mechanisms of injury associated body is exposed to physical forces causing tissue destruc- with creation of a stoma, key aspects of wound, ostomy, and tion. In most trauma situations, the physical forces are continence nursing care in trauma populations and presents kinetic in nature, and injury occurs when the energy of suggestions for future research. movement is transformed into other forms of energy, such as compression, shearing, and cavitation.4 Trauma nurses categorize mechanisms of injury into two broad cate- rauma affects all ages, races, and socio-economic classes gories: blunt injuries in which the skin surface is unbroken Tand ranks globally as a leading cause of morbidity and and penetrating injuries, which include a break in the skin mortality for all age groups except for persons aged 60 years integrity.5,6 In both mechanisms of injury, the mass of the or older.1 In 2003, more than 105,000 deaths in the United object striking the body and the velocity of the strike de- States were attributed to unintentional injuries.2 In that termine the amount of kinetic energy to which the body is same year, nearly half a million U.S.
    [Show full text]
  • Hemodynamic Profiles Related to Circulatory Shock in Cardiac Care Units
    REVIEW ARTICLE Hemodynamic profiles related to circulatory shock in cardiac care units Perfiles hemodinámicos relacionados con el choque circulatorio en unidades de cuidados cardiacos Jesus A. Gonzalez-Hermosillo1, Ricardo Palma-Carbajal1*, Gustavo Rojas-Velasco2, Ricardo Cabrera-Jardines3, Luis M. Gonzalez-Galvan4, Daniel Manzur-Sandoval2, Gian M. Jiménez-Rodriguez5, and Willian A. Ortiz-Solis1 1Department of Cardiology; 2Intensive Cardiovascular Care Unit, Instituto Nacional de Cardiología Ignacio Chávez; 3Inernal Medicine, Hospital Ángeles del Pedregal; 4Posgraduate School of Naval Healthcare, Universidad Naval; 5Interventional Cardiology, Instituto Nacional de Cardiología Ignacio Chávez. Mexico City, Mexico Abstract One-third of the population in intensive care units is in a state of circulatory shock, whose rapid recognition and mechanism differentiation are of great importance. The clinical context and physical examination are of great value, but in complex situa- tions as in cardiac care units, it is mandatory the use of advanced hemodynamic monitorization devices, both to determine the main mechanism of shock, as to decide management and guide response to treatment, these devices include pulmonary flotation catheter as the gold standard, as well as more recent techniques including echocardiography and pulmonary ultra- sound, among others. This article emphasizes the different shock mechanisms observed in the cardiac care units, with a proposal for approach and treatment. Key words: Circulatory shock. Hemodynamic monitorization.
    [Show full text]
  • Damage Control Surgery
    SAJS EditorialTrauma Damage control surgery Damage control surgery (DCS) has been one of the major pathic with a firmly established ‘vicious cycle’. Timmermans advances in trauma surgery over the past two decades and is et al. in this edition of SAJS have evaluated the factors pre- now a well-established surgical strategy in the management dicting mortality in DCS and have proposed specific criteria of the severely injured and shocked patient. DCS refers to a for DCS.12 They advise that DCS should be initiated when conscious decision by the surgeon to minimise operative time the pH is <7.20, the base excess worse than minus 10.5 and in a seriously injured patient when the combined effects of the core temperature less than 35OC. When a major injury is the magnitude of the injury and the markedly altered physi- recognised, however, the surgeon should not wait for these ological state of the patient preclude an immediate and safe criteria to be reached. These data provide uniformity and definitive operative procedure. DCS encompasses a change specific criteria as to when DCS should be undertaken. in the surgical mindset with realisation of the need in the The second stage of DCS is the initial operation. The severely injured and shocked patient to halt and reverse the surgeon should do the minimum required to rapidly control lethal cascade of events that include hypothermia, acidosis exsanguination (suture, ligation, temporary vascular shunt and coagulopathy, a sequence which has been termed the or packing) and to prevent spillage of gastro-intestinal con- ‘triad of death’.
    [Show full text]
  • Cardiac Arrest Due to Tension Pneumoperitoneum Caused by Esophagogastric Perforation and Pyloric Stenosis : a Case Report
    Shinshu Med J, 67⑵：113～119, 2019 Cardiac Arrest Due to Tension Pneumoperitoneum Caused by Esophagogastric Perforation and Pyloric Stenosis : A Case Report 1 ）＊ 1） 1） Hiroshi Miyama , Mayumi Okada , Hiroshi Takayama 1） 2） Hiroshi Imamura and Futoshi Muranaka 1） Department of Emergency and Critical Care Medicine, Shinshu University School of Medicine 2） Department of Surgery, Shinshu University School of Medicine Tension pneumothorax is one of the causes of sudden cardiac arrest with evidence of obstructive shock and subcutaneous emphysema. Emergency chest decompression is a treatment of choice in such a situation. Herein, we report a case of an out-of-hospital cardiac arrest due to tension pneumoperitoneum caused by esophagogas- tric perforation. A 40-year-old man with a history of duodenal ulcer and pyloric stenosis complained of sudden- onset abdominal pain and developed cardiac arrest during transportation to our hospital. He had jugular venous distention ; subcutaneous emphysema in the upper body trunk, arms, and neck ; and a markedly distended abdomen. Immediate needle-chest decompression was not effective, but after volume resuscitation, adrenaline administration, and abdominal decompression by nasogastric tube, spontaneous circulation was resumed. Radiological findings revealed tension pneumoperitoneum due to esophagogastric perforation. Emergency laparotomy was performed, and the perforation of the esophagogastric junction was detected. The patient was discharged from the hospital without any disability. Notably, in the treatment of a patient with cardiac arrest having subcutaneous emphysema, the cause of obstructive shock could exist not only in the chest, but also in the abdomen. Shinshu Med J 67 : 113―119, 2019 (Received for publication November 12, 2018 ; accepted in revised January 4, 2019) Key words : cardiac arrest, esophagogastric perforation, tension pneumoperitoneum decompression, successfully improved his circulation.
    [Show full text]
  • Septic, Hypovolemic, Obstructive and Cardiogenic Killers
    S.H.O.C.K Septic, Hypovolemic, Obstructive and Cardiogenic Killers Jason Ferguson, BPA, NRP Public Safety Programs Head, CVCC Amherst County DPS, Paramedic Centra One, Flight Paramedic Objectives • Define Shock • Review patho and basic components of life • Identify the types of shock • Identify treatments Shock Defined • “Rude unhinging of the machinery of life”- Samuel Gross, U.S. Trauma Surgeon, 1962 • “A momentary pause in the act of death”- John Warren, U.S. Surgeon, 1895 • Inadequate tissue perfusion Components of Life Blood Flow Right Lungs Heart Left Body Heart Patho Review • Preload • Afterload • Baroreceptors Perfusion Preservation Basic rules of shock management: • Maintain airway • Maintain oxygenation and ventilation • Control bleeding where possible • Maintain circulation • Adequate heart rate and intravascular volume ITLS Cases Case 1 • 11 month old female “not acting right” • Found in crib this am lethargic • Airway patent • Breathing is increased; LS clr • Circulation- weak distal pulses; pale and cool Case 1 • VS: RR 48, HR 140, O2 98%, Cap refill >2 secs • Foul smelling diapers x 1 day • “I must have changed her two dozen times yesterday” • Not eating or drinking much Case 1 • IV established after 4 attempts • Fluid bolus initiated • Transported to ED • Received 2 liters of fluid over next 24 hours Hypovolemic Shock Hemorrhage Diarrhea/Vomiting Hypovolemia Burns Peritonitis Shock Progression Compensated to decompensated • Initial rise in blood pressure due to shunting • Initial narrowing of pulse pressure • Diastolic raised
    [Show full text]
  • A Multicentric Case Series in Colombia
    ORIGINAL ARTICLE Damage Control Pancreatoduodenectomy for Severe Pancreaticoduodenal Trauma: A Multicentric Case Series in Colombia Luis F Cabrera1, Mauricio Pedraza2, Sebastian Sanchez3, Paula Lopez4, Felipe Bernal5, Jean Pulido6, Patricia Parra7, Carlos Lopez8, Luis M Marroquin9, Juliana Ordoñez10, Gabriel Herrera11 ABSTRACT Introduction: Emergency pancreatoduodenectomy is a procedure that is indicated for the management of severe pancreaticoduodenal trauma after damage control surgery. Objectives: To present our experience of pancreaticoduodenal trauma management with emergency pancreatoduodenectomy and damage control surgery. Materials and methods: Retrospectively recorded data of patients with severe pancreaticoduodenal trauma who underwent a pancreatoduodenectomy and damage control for trauma at a high-volume trauma center. Results: In a period of 6 years, four patients (three men and one woman, median age 17.5 years, range: 16–21 years) with severe pancreaticoduodenal trauma underwent a pancreatoduodenectomy and damage control procedure (gunshot n = 4), and in a second surgical procedure underwent gastrointestinal tract reconstruction. In total, 75% incidence of surgical site infection (SSI) was reported, 25% health- care-associated pneumonia, and 50% postoperative pancreatic fistula (POPF). Intensive care unit (ICU) of 12.25 and hospital stay of 29.5 days mean and no mortality. Conclusion: An emergency pancreatoduodenectomy can be a lifesaving procedure in patients with non-reconstructable duodenopancreatic injuries. Damage control surgery in pancreaticoduodenal trauma is an alternative for management although with high risk of morbidity. Keywords: Abdominal trauma, Advanced trauma life support care, Duodenum, Multiple trauma, Pancreas, Trauma severity indices. RESUMEN Introducción: La pancreatoduodenectomía de emergencia es un procedimiento que está indicado para el tratamiento del trauma duodenal pancreático severo después de la cirugía de control de daños.
    [Show full text]
  • Trauma Resuscitation and the Damage Control Approach
    SURGERY FOR MAJOR INCIDENTS anatomy’). This philosophy has increasingly been adopted in the Trauma resuscitation and the civilian environment. DCS describes the specific, systematic surgical approaches damage control approach focussing on normalizing physiology from the dual insults of injury and surgery, as opposed to providing immediate definitive Nathan West repair.3,4 DCRad incorporates diagnostic and interventional Rob Dawes radiological solutions used to treat severely injured patients.5 Recent history of trauma care Abstract Haemorrhage remains the biggest killer of major trauma patients. One- Advances in trauma care commonly occur during warfare, where third of trauma patients are coagulopathic on admission, which is exacer- high numbers of seriously injured soldiers are treated, although a bated further by other factors. Failure to address this results in poor out- landmark change was the introduction of the Advanced Trauma Ò comes. Damage control resuscitation is current best practice for bleeding Life Support (ATLS) programme in 1978. ATLS was originally trauma patients, and encompasses damage control surgery and damage targeted at doctors with little expertise in trauma and provides a control radiography. This review provides a summary of the latest con- structured system for recognizing life-threatening problems and cepts in the rapidly evolving field of trauma resuscitation management. instigating appropriate interventions. The ATLS ‘Airway, Keywords Damage control; massive haemorrhage; resuscitation; trauma Breathing, Circulation, Disability, and Exposure’ (ABCDE) mantra is familiar the world over. Whilst it is likely this approach has saved many lives over the years, with the advent of regional Introduction trauma networks and experience gained from large recent mili- tary campaigns, an approach that reaches beyond ATLS is now Damage control (DC) was first termed to describe measures required in civilian practice.
    [Show full text]
  • Recognizing and Treating Shock in the Prehospital Setting
    9/3/2020 Recognizing and Treating Shock in the Prehospital Setting 1 9/3/2020 Special Thanks to Our Sponsor 2 9/3/2020 Your Presenters Dr. Raymond L. Fowler, Dr. Melanie J. Lippmann, MD, FACEP, FAEMS MD FACEP James M. Atkins MD Distinguished Professor Associate Professor of Emergency Medicine of Emergency Medical Services, Brown University Chief of the Division of EMS Alpert Medical School Department of Emergency Medicine Attending Physician University of Texas Rhode Island Hospital and The Miriam Hospital Southwestern Medical Center Providence, RI Dallas, TX 3 9/3/2020 Scenario SHOCK INDEX?? Pulse ÷ Systolic 4 9/3/2020 What is Shock? Shock is a progressive state of cellular hypoperfusion in which insufficient oxygen is available to meet tissue demands It is key to understand that when shock occurs, the body is in distress. The shock response is mounted by the body to attempt to maintain systolic blood pressure and brain perfusion during times of physiologic distress. This shock response can accompany a broad spectrum of clinical conditions that stress the body, ranging from heart attacks, to major infections, to allergic reactions. 5 9/3/2020 Causes of Shock Shock may be caused when oxygen intake, absorption, or delivery fails, or when the cells are unable to take up and use the delivered oxygen to generate sufficient energy to carry out cellular functions. 6 9/3/2020 Causes of Shock Hypovolemic Shock Distributive Shock Inadequate circulating fluid leads A precipitous increase in vascular to a diminished cardiac output, capacity as blood vessels dilate and which results in an inadequate the capillaries leak fluid, translates into delivery of oxygen to the too little peripheral vascular resistance tissues and cells and a decrease in preload, which in turn reduces cardiac output 7 9/3/2020 Causes of Shock Cardiogenic Shock Obstructive Shock The heart is unable to circulate Obstruction to the forward flow of sufficient blood to meet the blood exists in the great vessels metabolic needs of the body.
    [Show full text]
  • Shock and Awe: a Dynamic Approach to Resuscitation
    Shock and Awe: A dynamic approach to resuscitation Critical Care Symposium October 28, 2017 Anna Perrello, RPA-C, MPAS Brian Kersten, PharmD, BCCCP, BCPS Disclosures • Brian Kersten o Nothing to disclose • Anna Perrello o Nothing to disclose Objectives • Identify and explain the physiology of various shock states including distributive, cardiogenic, obstructive and hypovolemic. • Discuss advantages and limitations to static and dynamic predictors of volume responsiveness. • Recognize techniques related to visualization of basic structures and medium identification during bedside ultrasonography. • Evaluate treatment options for shock states using dynamic measures for fluid resuscitation Shock • A heterogenous syndrome best defined as circulatory failure o Originates from mismatch between oxygen delivery (DO2) and oxygen consumption (VO2) • Often becomes apparent in setting of arterial hypotension Differentiating Shock Systemic Mixed Wedge Cardiac vascular venous pressure output resistance oxygen Hypovolemic - Hemorrhage ↓ ↓ ↑ ↓ - Dehydration Cardiogenic - Myocardial infarction ↑ ↓ ↑ ↓ - Arrhythmia - Cardiomyopathy Obstructive - Pulmonary embolism ↑↔ ↓ ↑ ↓ - Tension pneumothorax - Cardiac tamponade Distributive - Septic shock - Anaphylaxis ↑↔ ↑ ↓ ↑ - Neurogenic - Myxedema coma - Post-cardiopulmonary bypass Goals of Therapy in Shock • Restore effective tissue perfusion and normalize cellular metabolism by ensuring systemic oxygen delivery by 1. Aggressive and appropriate fluid resuscitation 2. Supporting CO and MAP • Above are titrated to
    [Show full text]