Ben Edwards 11 th Feb 2014

1. Ben Edwards 11th Feb 2014 Major Trauma

2. Outline • Major trauma networks • Trauma team • Initial Assessment and Management • <c>ABCDE • Damage control resuscitation • Hypotensive & haemostatic resuscitation • Damage control surgery

3. Trauma: Who cares? Emergency Admissions:A journey in the right direction? A report of the National Confidential Enquiry into Patient Outcome and Death (2007) A report of the National Confidential Enquiry into Patient Outcome and Death (2007)

4. History • NCEPOD publish “Trauma: who cares?” in 2007 • Major criticisms of current delivery of trauma care • Keith Willett appointed National Director of Trauma Care in 2009 • National Major Trauma Centre model of care started April 2012 • Full designation of major trauma centres in April 2013 • Overseen by regional trauma networks

5. Why the change • To understand why change was needed must understand who is affected • Predominantly young people of working age • Become tax consumers instead of tax contributors • Unnecessary loss of life • 20 lives/yr in Yorkshire & Humber region

6. Before the Major Trauma Network Injury Nearest A&E unit Tertiary referral centre

7. Why is that a problem? • Local hospitals • Lack of specialist services • Cardiothoracic • Vascular • Neurosurgery • Interventional Radiology • Necessitates transfer • Causes delay • Delay and transfer = worse outcomes

8. Yorkshire and the HumberMajor Trauma Network Q: What is a trauma network? A: a collaboration between providers and commissioners to deliver optimal major trauma care services in a geographical area. • It includes : • Major Trauma Centres • Pre-hospital Care • All other hospitals that deal with trauma – Trauma Units and local A&Es • Rehabilitation

9. Why is it needed? • A network is expected to improve outcomes for patients with Major Trauma through: • “Better co-ordination of care where patients are moved in a timely manner to the location best able to provide for their needs.” • This applies to every stage from initial care to rehabilitation. • Improving the quality of care of the severely injured patient at every stage of the pathway

10. Benefits? • 2011 SCHARR research estimates that between 5-15% more lives could be saved. • In Yorkshire and the Humber = 28 - 33 per year. • Y&H Regional Trauma Network would be cost effective if effective implementation costs less than £6–7 million • (Source: Cost Effectiveness of Regional Networks for Major Trauma in England 2011) • LOS reduction of 4 days = £5 million saving per annum • earlier transfers • more rapid and definitive care • fewer complications • (Source: NCEPOD Regional trauma system guidance for commissioners 2009)

11. More benefits? Reduction in the cost to the taxpayer • more people returning to non-dependent life • reduced disability • increased returns to work • fewer demands on social care • i.e. More people that pay tax rather than consume taxes!

12. Financial implications for hospitals • Tariff for patient care = income • Previously more injuries = the same money • Not rewarded for multiple operations etc. • Best practice tariff (BPT) change that • Multiple injuries = additional money (+£1500) • Trauma patients now bring in more money • But only if certain criteria are fulfilled

13. But not such a good deal for TUs • Loss of complex patients = loss income • But same levels of staffing required • Loss of skills & training • Lack of motivation to maintain standards of trauma care

18. Pathway Phasing Current Pathway Development to April 2014 Phase 1 From April 2012 Phase 2 From April 2013 Phase 3 From April 2014

19. Pre Hospital Care • Pre hospital triage tool • Bypass of trauma units for patients who trigger • Experience paramedic in control room to facilitate process • If patient unstable or >45 minutes from MTC consider going straight to trauma unit • Development of ‘Stop, Sort, Go’ protocol

20. Trauma Scoring Systems • The need to classify injuries objectively is fundamental to the delivery of trauma care (and its evaluation) • Allows data collection • TARN • Money • Comparisons between centres

21. Classification • Physiological • Trauma Score (TS) • Revised Trauma Score (RTS) • Anatomical • Injury Severity Score (ISS) • Abbreviated Injury Scale (AIS) • Not all injuries apparent at presentation

22. Trauma Score • Respiratory rate • Respiratory expansion • Systolic BP • Capillary refill time • GCS • Used to calculate need for transfer • Relates to mortaility

23. Revised Trauma Score • Weights more to head injury • GCS • Systolic BP • RR • Limitations in assessing GCS • Alcohol, illicit drugs • Can substitute best motor response

24. Abbreviated Injury Scale • Simple numerical method for grading and comparing injuries by severity. • Originally intended for use with vehicular injuries • Grades injuries on an scale ranging from 1 (minor) to 6 (lethal) • Does not reflect combined effects multiple injuries • Basis of ISS

25. Injury Severity Score (ISS) • Used in calculation of BPT • Sum of squares of the highest AIS grade in the 3 most severely injured body regions. • Six body regions are defined • thorax, abdomen and visceral pelvis, head and neck, face, bony pelvis and extremities, and external structures. • Only one injury per body region is allowed. The ISS ranges from 1-75, and an ISS of 75 is assigned to anyone with an AIS of 6.

27. On arrival met by trauma team

28. In Hospital -Trauma Team Activation

29. Resuscitation Priorities Trauma team allows for horizontal assessment of: • <C> = Control of exsanguinating haemorrhage • A = Airway with C-spine protection • B = Breathing with ventilation • C = Circulation with haemorrhage control • D = Disability: Neurologic status • E = Exposure / Environment

30. <C> = Control of exsanguinating haemorrhage • Direct pressure • Indirect pressure • Elevate • Tourniquet • Haemostatic agents • Don’t forget scalp wounds

31. New ways of managing penetrating trauma • Quick to use • Apply band around limb • Twist ‘windlass’ until arterial bleeding stops • Document time of application CAT Tourniquet

32. New ways of managing penetrating trauma CELOX Gauze • Gauze dressing impregnated with chitosan (shrimp shells) • Bonds to specific sites on red blood cells and platelets, forming a gel like clot • Stuff/pack into wound and apply direct pressure over

33. A = Airway with C-spine protection • Time critical that the airway is secured as rapidly as possible if GCS<9 • National standard is <30mins • Facilitates rapid transfer for WBCT • Direct link to neurological outcome • But the trauma airway is likely to be difficult • NAP4 also shows that airway complications are most likely to occur in the ED

34. Absolute Indications for intubation • Inability to maintain and protect own airway regardless of conscious level • Inability to maintain adequate oxygenation with less invasive manoeuvres • Inability to maintain normocapnia (spontaneous PaCO2 <4.0 kPa or >6.0 kPa) • GCS ≤8 • Patients undergoing transfer with: • Deteriorating conscious level (≥2 points on motor scale) • Significant facial injuries • Seizures. (See NICE Guidelines for intubation and ventilation in the presence of brain injury)

35. Relative Indications for Intubation • Haemorrhagic shock, particularly in the presence of an evolving metabolic acidosis. • Agitated patient (hypoxia & hypovolaemia are prime causes of agitation) • Multiple painful injuries (humanitarian) • Transfer to another area of the hospital (e.g. vascular Angio/theatres/GITU)

36. Securing the Airway • Recommend modified RSI • Assume c-spine is unstable • In line immobilisation • Remove front of hard collar (occludes access to cricothyroid membrane) • Elective use of bougee • Uncut ETT if any burns/blasts • Tape rather than tie to reduce venous pressure

37. Drugs • Careful dose titration required (hypovolaemia and acidosis). • If head injury is suspected attenuate the stress response to laryngoscopy (alfentanil 10µg kg-1 is effective) • Ketamine is the agent of choice in the haemodynamically unstable patient • not contraindicated in brain injury (minimises hypotension in those with hypovolaemia and abnormal cerebral autoregulation) • Etomidate • not recommended due to adrenal suppression • Contra-indicated in head injury (uncouples cerebral blood flow and metabolism)

38. Post Intubation Care • Aim VT 6-8 ml/kg, Pmax< 30, arterial pC02 4.5 – 5 kPa • Consider inserting an arterial line • Changing airway pressure may indicate a change in compliance • pneumothorax or lung injury. • Maintain anaesthesia using volatile or infusions (i.e. Propofol/Alfentanyl) • Volatile anaesthesia can increase cerebral blood flow &ICP • < 1 MAC, switch to i.v. agents as soon as possible.

39. B = Breathing with ventilation • Immediately life threatening injuries requiring urgent intervention • Tension & open pneumothorax • Decompression (needle or thoracostomy) • Haemothorax • Drainage and volume replacement • Flail chest • Rib fracture fixation • Tamponade • Temporising pericardiocentesis • Definitive or resuscitative thoracotomy

40. B = Breathing with ventilation Imaging • Obtain CXR at the earliest opportunity • rib fractures and pneumothorax (particularly anterior) may be missed and only detected clinically or on CT scan –don’t delay CT • Chest ultrasound is useful investigation for pneumothorax and tamponade

41. Open Thoracostomy •  Chest drain without the actual intercostal catheter: • The wound is left open. • Enables rapid decompression of a tension pneumothorax in an intubated patient • Positive pressure ventilation prevents the thoracostomy wound from acting as an open, ‘sucking’, chest wound.

42. C – Circulation with haemorrhage control The key is to turn the tap off! • In the interim, the core principles are that of Damage Control Resuscitation • Concepts primarily conceived in the military • Improved survival from battlefield trauma • Landmark paper from Jansen et al Jansen J et al. Damage control resuscitation for patients with major trauma. BMJ 2009;338:b1778

43. Classes of Shock

44. The lethal triad • Proven detrimental effects of aggressive fluid resuscitation • Hypothermia • Independent predictor of mortality • Acidosis • Higher mortality in critical care • Coagulopathy • > 4x mortality

45. Turning off the tap • Measures as per <C> • Bind the pelvis • Splint the femur(s) • Damage control surgery • Interventional radiology

46. Damage control resuscitation • Permissive hypotension + haemostatic resuscitation + damage control surgery • Permissive hypotension = “A strategy of deferring or restricting fluid administration until haemorrhage is controlled, while accepting a limited period of suboptimum end organ perfusion” • Haemostatic resuscitation = very early use of blood and blood products as primary resuscitation fluids Jansen J et al. Damage control resuscitation for patients with major trauma. BMJ 2009;338:b1778

47. Permissive hypotension • Should not be used in head injuries • Most applicable to penetrating trauma • Other terms • Hypotensive resuscitation • Delayed resuscitation Jansen J et al. Damage control resuscitation for patients with major trauma. BMJ 2009;338:b1778

48. Bickel WH et. al • Randomised 2 groups with penetrating trauma and BP <90 • Immediate • Delayed • BP >100 post anaesthesia Bickell WH et al, NEJM 1994; 331:1105-9

49. Outcomes • Statistically significant findings: • Survival higher in delayed group • Stay shorter in delayed group • Trend towards • Higher intra-op blood loss in the immediate group • ? More complications in immediate group • Not statistically significant Bickell WH et al, NEJM 1994; 331:1105-9

50. Outcome of Patients with Penetrating Torso Injuries, According to Treatment Group