PERIOPERATIVE COMPLICATIONS OF TRAUMA (Near) Misses Case Discussions

1. PERIOPERATIVE COMPLICATIONS OF TRAUMA(Near) MissesCase Discussions Linda E. Pelinka, M.D., Ph.D. Medical University of Vienna and Ludwig Boltzmann Institute for Experimental & Clinical Traumatology Vienna, Austria, European Union TRAUMA

2. THE PREHOSPITAL SETTING Airway management Scoop & Run or Stay & Play?

3. …while it is critically important to learn the skills of intubation, knowing the sequence and tasks alone does not guarantee success.

4. IS THE TUBE WHERE IT SHOULD BE? Visualization of ETT passing through cords Auscultation of breath sounds Condensation inside the ETT Symmetric chest rise/fall with ventilation Absence of sounds over epigastrium Have all been shown to be unreliable in the hospital setting Are likely to be even less reliable in the prehospital setting Swanson ER et al. Air Medical Journal 2005; 24/1: 40-6.

5. MONITORING • Pulse Oximetry • Capnography

6. MONITORING • PULSE OXIMETRY – INDIRECT techniqueis reliable for oxygenation, but measures oxygenation indirectly. • CAPNOGRAPHY – DIRECT technique detects breathing abnormalities directly and almost immediatelyapnea: loss of CO2 wave. Green SM, Krauss B, Academic Emerg Med 2002; 9: 35-42.

7. AMERICAN POINT OF VIEW: Patient unconscious and full stomach, INTUBATION MANDATORY to avoid danger of vomiting & aspiration, however: • RSI • MONITORING MANDATORY

8. EUROPEAN POINT OF VIEW: Patient unconscious, however: • Breathing spontaneously • Sufficient O2sat considering asthma • Full stomach • Hospital 15 min away • WHY INTUBATE? • RISK OF INTUBATION vs. RISK OF ASPIRATION

9. Outcomes after out-of-hospital endotracheal intubation errors , Wang HE et al, Resuscitation 2009; 80/1: 50-55. Results: of 1954 out-of-hospital ETI, 444 patients (22.7%) experienced one or more ETI errors: • Failed ETI in 359 (15%) • Multiple ETI attempts in 62 (3%) • Tube misplacement or dislodgement in 61 (3%) Henry E. Wanga,

10. Emergency ventilatory management in hemorrhagic states: elemental or detrimental? Early intubation of polytrauma is associated with increased mortality. Evidence supports the scoop and run approach. Pepe P et al. J Trauma 2003;54:1048-55.

11. Safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury. Shatney CH et al. Am J Surg 1995; 170: 676-80. Airway management should avoid producing or worsening neurological deficits secondary to movements of the c-spine. Presence of a foreign body in the spinal canal increases the risk.

12. Endotracheal intubation in the field improves survival in patients with severe head injury. Prehospital intubation was found to improve survival significantly in TBI patients with GCS 8 or less. Survival increased from 64% to 74%. Winchell RJ, Hoyt DB: Arch Surg 1997; 132: 592-7.

13. Prehospital airway managementfor severe brain injury Parr M. Resuscitation 2008: 76, 321-322 Prehospital airway management in TBI is receiving critical review. There are a growing number of reports suggesting an association between early intubation and increased mortality.

14. Prehospital airway managementfor severe brain injury Parr M. Resuscitation 2008: 76, 321-322 It is well recognized that hypoxaemia and hypotension are common in the prehospital phase of TBI and have a significant impact on outcome. It would therefore appear to be logical to advocate prehospital RSI & intubation for patients with severe TBI. We need definitive studies.

15. PREHOSPITAL INTUBATION of SEVERE TBI? GOAL: MINIMIZE SECONDARY BRAIN DAMAGE trauma.org 2007

16. HYPOXIA HYPOTENSION SECONDARY BRAIN DAMAGE DOUBLE MORTALITY AFTER TBI Chesnut R, New Horizons 2000

17. Trauma in the prehospital setting:QUESTION #1 Is an airway necessary right away or can it wait until the hospital?

18. Trauma in the prehospital setting: QUESTION #2 If an airway is necessary, is there any additional (airway) difficulty?

19. Patients die of LACK of OXYGEN… …not of LACK of an ETT consider supraglottic devices

20. Main problems blood loss and shock • Scoop &run w/o intubation (Europe): GET TO SURGERY ASAP • Hemo-pneumothorax: • NO INTUBATION • W/O CHEST DRAIN • RISK OF INTUBATION vs. RISK OF ASPIRATION

21. THE ER SETTING emergency room priorities

22. SECONDARY BRAIN DAMAGEVICIOUS CYCLE ICP CBV CPP CBF AUTOREGULATION

23. Differential Diagnosis Hypotension Tachycardia Tachypnea

24. Is it really what I think it is? Assuming is actually Frequency Gambling

25. In the head-injured, unresponsive patient: CT is the diagnostic METHOD OF CHOICE: from a medical point of view from a legal point of view from an ethical point of view

26. In minor head injury CT may be negative despite brain damage. If CT is negative consider MRI.

27. Survival of trauma patients who have prehospital tracheal intubation without anaesthesia or muscle relaxants • If patients are so deeply comatose that they do not require any anaesthesia or muscle relaxant for intubation, prognosis is largely hopeless. • In an observational study of 486 patients intubated prehospital without anaesthetic drugs, only 1 patient survived to hospital discharge. Lockey D, et al. Br Med J 2001;323:141.

28. Two things are infinite –the universeand human stupidity… ...and I’m not sure about the universe. Albert Einstein

29. THE OR SETTING hemorrhagic shock airway management postoperative neuroimaging

30. Use of Recombinant Activated Factor VIIa to Treat the Acquired Coagulopathy of Trauma Conclusion: Animal studies: stronger clot formation. Clinical study: decreased blood loss, decreased transfusions, no increased thrombotic complications. Potential usefulness of rFVIIa in patients with acquired coagulopathies from both blunt and penetrating trauma, efficacy of aFVIIa in reversing coagulopathy of trauma JB Holcomb, J Trauma 58: 1298-1303; 2005.

31. Decreased transfusion utilization and improved outcome associated with use of rFVIIa as an adjunct in trauma. Multicenter, prospective, double-blind RCT trial of efficacy and safety of recombinant factor VIIa as adjunctive therapy in trauma. 32 centers, 8 countries, 277 pts (50% blunt/50% pen) First dose of rFVIIa following 8th unit of PRC, add. doses 1 & 3 hrs later (200+100+100 ug/kg) D Boffard, B Warren, J Trauma 57: 451; 2004. 1 of 2

32. Findings: Decreased transfusions in penetrating trauma, but not statistically significant Statistically significantly decreased transfusions in blunt trauma. No safety issues, no thromboembolic events. Decreased transfusion utilization and improved outcome associated with use of rFVIIa as an adjunct in trauma. D Boffard, B Warren, J Trauma 57: 451; 2004. 2 of 2

33. ADRENERGIC AGENTS ICU vs OR

34. Anesthetic Management of a Patient in Prone Position with a Drill Bit Penetrating the Spinal Canal at C1-C2, using a Laryngeal Mask Valero R et al. Anesth Analg 2004; 98:1447-50.

35. CHECKING CT AFTER BRAIN SURGERY IS STATE OF THE ART

36. TAKE HOMEMESSAGES

37. AMERICAN POINT OF VIEW: Patient unconscious and full stomach, INTUBATION MANDATORY to avoid danger of vomiting & aspiration, however : • RSI • MONITORING MANDATORY

38. EUROPEAN POINT OF VIEW: Patient unconscious, however: • Full stomach • Hospital close by • Sufficient O2sat • Risk of intubation vs. Risk of aspiration

39. Hemorrhagic Shock Get to surgery ASAP Scoop & Run over Stay & Play

40. Is it really what I think it is? Assuming is actually Frequency Gambling

41. In the head-injured, unresponsive patient: CT is the diagnostic METHOD OF CHOICE: from a medical point of view from a legal point of view from an ethical point of view

42. In minor head injury CT may be negative despite brain damage. If CT is negative consider MRI.

43. CHECKING CT AFTER BRAIN SURGERY IS STATE OF THE ART