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Trauma and Cardiac Resuscitation

Trauma and Cardiac Resuscitation. Dr. Paul Pageau Staff Physician Assistant Fellowship Director EMUS Department of Emergency Medicine University of Ottawa The Ottawa Hospital. Objectives. General approach to Trauma/Resuscitation patients (A-B-C-D)

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Trauma and Cardiac Resuscitation

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  1. Trauma and Cardiac Resuscitation Dr. Paul Pageau Staff Physician Assistant Fellowship Director EMUS Department of Emergency Medicine University of Ottawa The Ottawa Hospital

  2. Objectives • General approach to Trauma/Resuscitation patients (A-B-C-D) • Approach to patient with multisystem trauma (MVC, penetrating, and other) • Approach to asystole/V-fib/STEMI patient and resuscitation, including drugs and therapeutic hypothermia • Trauma code: Outline role of Emergency Physician, Emergency team, TTL, and other services

  3. General Principles of Resuscitation • Preparation • Triage (multiple and mass casualties) • Teamwork • Leadership • Communication • Crisis Resource management • Situation awareness

  4. Trauma A-B-C’s Primary Survey • A – Airway and C-spine • B – Breathing and Ventilation • C – Circulation and Hemorrhage control • D – Disability (Neuro) • E – Exposure and Environment control

  5. Adjuncts to Primary Survey • Monitoring • Catheters • eFAST • Consider transfer/ Trauma Code

  6. Secondary Survey • Head to Toe (finger or tube) • History and Physical examination • Continual reassessment of Vital signs • Complete Neuro exam • Specific radiologic evaluation (CT)

  7. Code One Trauma EP on duty +- Res/students, 3 RN’s (Chart, Action/Task) • Trauma Team Leader (Gen Surgery or Emerg staff) • Gen Surgery Sr Resident • Anaesthesia Resident • 2 Respiratory Therapists • 2 Patient Transport Workers • Advance care nurse practitioner – trauma • Clinical manager in ED • Trauma coordinator • Security • OR is notified • Trauma Dept is notified

  8. Code One Trauma • TTL is EP on duty until TTL on call arrives (<20min) • Gen Surg Resident may assume TTL role depending on Level of training • Anaesthesia takes direction from TTL but mainly manages airway +- pain medication • RN’s: IV catheters, monitoring, charting, other catheters, facilitating, anticipating • RT’s: Airway assistance, Ventilation, monitoring

  9. Trauma Case 1 Hx: • 11yo ATV no helmet, Collided with tree • Altered LOC, hematoma ant scalp, Ant chest contusion • EMS Vitals: HR130, BP80/60, Sats 90%RA, GCS=10, PERL • Long transport from Trail • IVF 1L

  10. Trauma Case 1 • Boarded and collared wet clothes • Vitals HR120, BP90/65, Sats 90% on O2, RR25, GCS=11, T34.8 tymp • Vomitting Primary Survey: • Airway: moaning, emesis on face • Cspine protected • Decreased A/E on Right, dull percsn • Trachea midline • Decreased Cap refill • PERL • FAST pos pleural fluid, neg peritoneal fluid

  11. Trauma Case 1 • pt vomits just prior to ETT • roll onto side and suction • pt develops pulseless VF when rolling • defibrillate 2J/kg X1 • vitals return to baseline

  12. Trauma Case 1 Secondary Survey: • Right hemotympanum • Forehead abrasion and hematoma • Right chest contusion • Pelvis stable, Abdo soft Disposition: • Transfer to Tertiary care/ICU

  13. Trauma Case 2 • Large Community Hospital. OB/Anaesthesia in house, Peds often in house • EMS presents unannounced with 35yr female MVC, VSA, 30wks + pregnant. Hx: • 35 yo female. 30 wks+ pregnant, Belted passenger, T-boned,. • EMS on site <5min: VSA, CPR and epinephrine X2, intubated, 1L NS • Arrival to ED after 25 mins downtime

  14. Trauma Case 2 Interventions?: • OB stat • Peds Primary Survey: • Intubated • Multiple right rib fractures – soft chest ?Air Entry on R • VSA – CPR in progress

  15. Trauma Case 2 Interventions?: • perimortem C/S • ?Chest tube R Secondary Survey: • Pupils fixed dilated • blood from L ear and visible brain matter R skull • Pregnant abdomen • Pelvis unstable

  16. Cardiac Arrest and ResuscitationPrinciples: Chain of survival: • Recognition and activation • Early CPR • Rapid defibrillation • Advanced life support • Integrated post-cardiac arrest care

  17. Cardiac arrest • Call for help, Defibrillator, CPR • Shockable rhythm?  200J  CPR • Asystole/PEA  CPR  Epi 1mg q3-5min, Atropine 1mg q3-5min X3 • Check for shockable rhythm q2min CPR • Treat contributing factors (H’s and T’s) • Consider antiarrhythmics: amiodarone 300mg, or Lidocaine 1mg/kg, • Consider magnesium 1 – 2 gms for torsades

  18. ROSC • Evaluate for STEMI  PCI/code STEMI • In comatose pts evaluate for therapeutic hypothermia • Stabilize, monitor, definitive care

  19. Objectives • General approach to Trauma/Resuscitation patients (A-B-C-D) • Approach to patient with multisystem trauma (MVC, penetrating, and other) • Approach to asystole/V-fib/STEMI patient and resuscitation, including drugs and therapeutic hypothermia • Trauma code: Outline role of Emergency Physician, Emergency team, TTL, and other services

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