TRAUMA AND SURGICAL RESUSCITATION SEMINAR

1. TRAUMA AND SURGICAL RESUSCITATION SEMINAR Matthew Croxford Colorectal & General Surgeon Western Health Chief Medical Officer Motorsport Safety & Rescue

3. Seminar Objectives Describe symptoms & signs of shock & haemorrhage Post-op setting Trauma setting Take appropriate measures to resuscitate a patient with haemorrhage Assess need for ongoing monitoring of resuscitative measures Recognise importance of a team approach & the need to mobilise support

4. SHOCK

5. SHOCK Definition: Decrease in tissue perfusion to a point at which it is inadequate to meet cellular metabolic needs

6. SHOCK

7. SHOCK

8. EFFECTIVE MANAGEMENT Initial step in management = recognise its presence! Second step = identify the probable cause Initiate treatment simultaneously with attempt to identify the probable cause

10. Case Scenario 1 You receive a trauma call to the ED � paramedics have called � they will be arriving in 4 minutes with a 34 year old patient with a BP of 80 systolic and a stab wound to the back between the shoulder blades What form of shock might he be suffering from? Haemorrhagic shock? �Pump failure� due to cardiac tamponade? �Pump failure� due to tension pneumothorax? What action may be necessary? Depends on cause BUT Immediate attention to ABCs, oxygen, IV fluids Diagnosis and definitive management

11. CLINICAL FEATURES Follow a logical sequence Primary Survey A - Airway (Cx spine control) B - Breathing and ventilation C - Circulation with haemorrhage control D - Disability: Neurological status E - Exposure/Environmental control �How are you?�

12. A - Airway Look Central cyanosis �See-saw� or abdominal breathing Accessory muscles Tracheal tug Altered conscious level Airway obstruction Listen Grunting, snoring, hoarseness, stridor Feel Airflow on inspiration & expiration

13. B - Breathing Look Cyanosis/accessory muscles Respiratory rate Sweating Raised JVP Patency of chest drains Remember O2 sats do not detect hypercapnia Listen Noisy breathing Clearance of secretions Ability to talk in sentences Percussion note Auscultation Feel Position of trachea Surgical emphysema or crepitus

14. C - Circulation Hypovolaemia until proved otherwise Haemorrhage must be rapidly excluded Overt or covert Unless obvious signs of cardiogenic shock Cool & tachycardic = hypovolaemic shock

15. C - Circulation Look Reduced peripheral perfusion Pallor, coolness, collapsed veins BP may be normal External haemorrhage � wounds, drains Concealed haemorrhage � beware the empty drain thoracic, abdominal, GI tract, pelvic or femoral # Altered conscious level Cerebral perfusion Feel Pulses � peripheral and central Rate, quality, regularity, equality

16. 70 kg male Rule of 3:1 for replacement � need as much as 300ml of electrolyte for each 100ml of blood loss70 kg male Rule of 3:1 for replacement � need as much as 300ml of electrolyte for each 100ml of blood loss

18. D - Disability: Neurological Status Pupils / GCS AVPU system A � Alert V � responds to verbal stimulus P � responds only to pain U � unresponsive to any stimulus Sedatives, analgesics, anaesthetic drugs Hypoglycaemia Review the ABCs � missed something

19. E - Exposure Patient must be adequately exposed Avoid hypothermia Warm blankets/warming device Warmed IV fluids Respect dignity If at any time the patient deteriorates Reassess the ABCs

21. Case Scenario 2 An 81 year old woman with diabetes is admitted to the ward for routine observation after a straightforward balloon dilatation of a stenosis in her left common iliac artery. As the Intern, you are called by her nurse as her Pulse was 80 and BP was 100/60 and she looked a little pale. How would you respond?

22. Case Scenario 2 Examination shows the above observations but she is also peripherally shut down. � What else would you do? Review of left leg showed no swelling at femoral puncture site and weak distal pulse. Some mild discomfort in left iliac fossa. Review of her medication chart reveals beta-blockers and pre-procedure BP of 160/90. What now?

23. Case Scenario 2 Non-sustained response to 500ml bolus fluid. What now? Laparotomy reveals large bleed from ruptured common iliac artery. What is role of CT scan here?

29. Management Assume UNDERVOLUME is the cause unless Obvious cardiogenic cause Tension pneumothorax (raised JVP) STEP 1 � Resuscitate STEP 2 � Review response STEP 3 � Report to & involve senior colleagues

30. Management AIRWAY Protected in all, secured if potentially compromised Jaw thrust/chin lift Nasopharyngeal/oropharyngeal airway BREATHING/OXYGENATION ETT or surgical airway Supplemental O2 in ALL cases Pulse oximetry Tension pneumoTx Immediate chest decompression

31. Management CIRCULATION Control bleeding � external pressure/operative intervention 2 large bore IV cannulae (14G = 2x flow of 16G) Upper extremity peripheral is best (CVC/cut down) Type & X-match/Hb/clotting Rapid infusion of crystalloid/colloid 500ml bolus � may need 2-3 litres in adult trauma Type-specific or O-negative blood Do NOT use vasopressors

32. Adjuncts to Management ECG monitoring Dysrhythmias may indicate aetiology Urinary catheter Indicator of volume status/renal perfusion Beware urethral injury in trauma setting NG tube Decrease risk of aspiration

33. Adjuncts to Management Monitoring Ventilatory rate & ABGs Pulse oximetry Blood pressure Body temperature Urine output Look for return of normal peripheral perfusion X-Rays & Diagnostics Chest/Pelvis/Lateral Cx spine Remember a normal Cx spine XR does not exclude an injury FAST scan CT scan Beware the unstable patient in radiology

35. Response to Resuscitation Frequent re-evaluation Cardio-respiratory parameters Urine output - >0.5 ml/kg/hr Repeated clinical examination Look for new findings Relief of severe pain Titrate dose � smallest effective dose Avoid resp depression or masking subtle injuries

36. Refractory Shock Underestimation of degree of hypovolaemia Failure to arrest haemorrhage Presence of tamponade or tension pneumothorax Underlying sepsis Secondary CV effects due to delay in treatment Further action is necessary!

37. Case Scenario 3 A 35yr old woman underwent an uncomplicated laparoscopic cholecystectomy eight hours ago. You are the night Intern and are called by the nurse as the patient is anxious, and is complaining of right shoulder tip pain. How will you respond? Her obs. are P 120, BP 90/50, RR 21 and Temp 37.0 40 ml haemoserous fluid in Redivac drain bottle. What now?

38. Post-op Patient THINK SURGICAL FIRST = BLEEDING = Involve the surgical team Examine the patient Examine the charts Trends in PR, BP, RR, urine output, epidural doses Look at the fluid balance chart Think of other causes Septic shock Inadequate replacement of fluid losses Effects of opiates, epidurals, Non-surgical causes � AMI, PE, dysrhythmias

39. Case Scenario 4 A 69 yr old man has undergone TURP three hours ago and has just returned to the ward.. The nurse rings you as she is �not happy� with the way he looks as he is shaking uncontrollably. You are scrubbed in theatre when she rings. How would you respond? His observations were�P 110, BP 95/60, T 38.5, returned fluid in urinary irrigation bag was pink in colour with no clots. What is your differential diagnosis? How to proceed from here?

40. Case Scenario 5 A 23 yr. old trail bike rider has been brought in to the Emergency Department by his mates with what looks like a fractured right femur. There has not been any loss of consciousness but he is complaining of some diffuse abdominal pain. His observations on arrival were P 90, BP 110/50, RR 18. You have been asked to assess him and to insert an I/V. His right femur is clinically fractured and the abdomen is diffusely tender and non-distended There are no other injuries apparent but you have difficulty with the IV insertion as his veins seem to be collapsed. What do think is going on here? What treatment plan would you write-up? What investigations should be undertaken and how quickly would you want them done ( it is very busy in ED tonight ) ?

42. Summary Structured system of assessment reduces serious omissions Identify those in need of immediate life-saving resuscitation Assess and treat simultaneously Reach a diagnosis to account for clinical deterioration Formulate and institute a plan of definitive treatment

43. Summary Repeated clinical assessment is the cornerstone of good practice Investigations should be selective and carried out in a safe environment Inform and involve your senior colleagues at an early stage Consider the level of care necessary at each stage