Immediate life threats in trauma
- Massive external hemorrhage
- Critical airway compromise
a) Critical/refractory hypoxia (<90% SpO2 despite maximal noninvasive ventilation)
b) Dynamic airway
- Anticipate evolving disruption of airway
- Head/neck injuries that are expected to worsen
Intubation causes an increase in intrathoracic pressure,
resulting in a decrease in right atrial pressure which negatively impacts both hemorrhagic and obstructive shock.
Once these two immediate life threats have been ruled out or managed,
resuscitation should focus on hemodynamic optimization before definitive airway management.
Endotracheal intubation can usually be delayed until adequate hemodynamic resuscitation.
Assess occult shock in first 15 mins
- Calculate Shock index (HR/SBP) and/or delta Shock Index
if shock index > 1 or delta Shock Index ≥ 0.1, assume occult shock
- Assess the lowest BP measured and trend of BP over time
if isolated or persistent SBP <110, assume occult shock
When receiving handover from EMS ask not only the most recent BP but the lowest BP recorded
- FAST positive + Flat IVC
- Presence of peripheral pulses and signs of poorly perfused extremities
- Altered LOA in the absence of severe head injury
delta SI (peak SI - baseline SI)
Consider the patient's age, blood pressure medications and baseline blood pressure in assessing for occult shock
Vasopressors only if neurogenic/spinal shock suspected
Controlled resuscitation (permissive hypotension)
to a target SBP of ≥70 is reasonable in most young
Large volumes of crystalloid contribute to the trauma triangle of death
Massive transfusion
Activate the MTP :
- Obvious shock state
- Shock index >1
- Delta shock index ≥0.1
- ABC score ≥ 2
- If none of these are present, consider the resuscitation intensity
patients who require 4 units of any combination of crystalloids or blood products
to maintain adequate perfusion are considered to have high resuscitation intensity
https://emergencymedicinecases.com/trauma-first-last-15-minutes-part-2/
Important source of massive hemorrhage :
Abdominal visceral organ, Long bone fractures
Venous hemorrhage of Unstable pelvic fracture
Consider a DRE to assess for bleeding and bone shards that suggest an open pelvic fracture before placing the pelvic binder
While the rectal exam is no longer recommended to assess for high riding prostate
there are 3 situations where a rectal exam is warranted:
Spinal cord injury (assess for sacral sparing), Pelvic fracture (assess for open fracture) and Penetrating abdominal trauma (assess for gross blood).
Examine the pelvic bone
- Do not place outward pressure or assess for vertical instability.
- Do not rock the pelvis.
- Do apply inward pressure on the iliac wings to assess for movement.
If there is movement, do maintain the inward pressure immediately followed by application of the binder.
- When applying the trochanteric binder, do not apply the binder over the iliac crests.
Do place the binder over the greater trochanters.
Do place the legs in internal rotation and tape them together at the ankles.
This will decrease the anatomic bleed space.
Do obtain a post reduction x-ray if time permits.
No evidence-based absolute BP targets in early trauma resuscitation
Reasonable guide is the following:
- Presumed hemorrhagic shock : Systolic BP ≥ 70 mmHg
- Presumed spinal shock : MAP ≥ 80-90 mmHg
- Shock in the severe head injured patient
(GCS < 8, lateralizing findings, depressed skull fracture) : MAP ≥80 mmHg
Vasopressors are only indicated in presumed spinal shock in the setting of trauma.
Norepinephrine is the vasopressor of choice based on current guidelines.
It is thus recommended by our experts to lower the induction agent dose
by 50-75% of the usual RSI induction agent dose for all patients with a shock index of ≥ 1, even when using ketamine.
A higher paralytic dose is recommended because the drug may not circulate as readily in the shocked patient
Avoid laying flat throughout the resuscitation : reverse Trendelenburg or sitting up
留言列表
CV (7)
