Meeting Room 1-2nd Floor Topeka 1:00pm to 4:00pm April 26, … · 2010-07-01 · Northeast Regional...

Northeast Regional Trauma Council General Membership Meeting

St. Francis Hospital Meeting Room 1-2nd Floor

Topeka 1:00pm to 4:00pm

April 26, 2010

Minutes Cal to order and Welcome Dr. James Longabaugh called the meeting to order at 1:05pm. He “thanked” St. Francis Health Center for hosting the meeting. He asked all members to introduce themselves and the organization that they represent. Dr. Longabaugh reminded the members to complete their evaluations throughout the day, sign the sign-in roster, and complete their certificate of attendance. Legislative Advocacy & Session Update Due to other scheduling conflicts, Senator Schmidt was unable to present. Midwest Transplant Network Chad Bittle provided an overview of the Midwest Transplant Network and information on the number of people in our region awaiting transplants. Click here to view his presentation. Update on Public Health In Kansas Dr. Jason Eberhart—Phillips provided the presentation. His presentation provided information on HINI, Clean Indoor Act, and other KDHE legislative activities. Click here to view his presentation. Trauma System Development Rosanne Rutkowski provided the presentation. Her presentation provided information on the program’s achievements, current projects, and future goals. Click here to view her presentation. Interpreting Trauma Registry Data Dee Vernberg provided trauma registry data for the NE region and included information on trauma registry inclusion criteria, over and under triage, and data on the receipt of EMS patient care reports. Resuscitation of the Trauma Patient In the absence of Dr. Charlie Richart, Dr. Michael Moncure provided the presentation. Click here to view his presentation.

Subcommittee Updates

Education-Injury Prevention Darlene Whitlock and Liz Carlton provided the education and injury prevention update.

Injury Prevention Report NERTC hosted a Fall Prevention Workshop in December 2009. After the workshop was conducted, mini fall prevention grants were made available. Recipients of the grants were Health Innovations Network

of Kansas (HINK), Inc., Coffey County Hospital, University of Kansas Hospital, Lawrence Memorial Hospital, F.W. Huston Medical Center, Shawnee Mission Medical Center, and Pottawatomie County EMS. The regional trauma council provided funding to support the implementation of KDOT’s SAFE Teen Driving program in the region. The program allows high schools to compete against each other to increase seatbelt usage.

Education Report Classes supported in 2009-2010

o PHTLS Overland Park Regional Medical Center

Held June 2009

American Medical Response-Wabaunsee County Held October 2009

o TNCC

HINK-Coffey County Hospital Held August 2009

Ransom Memorial Hospital

Held March 2010

Mercy Hospital-Manhattan Held January 2010

o RTTDC

Lawrence Memorial Hospital Held September 2009

St. John’s Hospital-Leavenworth

Held December 2010

Upcoming: ATLS class, Stormont Vail on July 23rd & 24th.

The Trauma Program, the FLEX program and KFMC collaborated to conduct a trauma education needs assessment survey. A survey was sent to hospital administrators and ED managers and a survey was sent to EMS directors. The results of the survey were included in the meeting packet. The RTC would like to take the information gained from the survey and develop a plan/strategy to meet the needs identified in the survey. Click here to view trauma education needs assessment results.

Trauma Program Website: Organizations, as they schedule trauma education classes, were encouraged to send their course information to Jeanette to post on the trauma education calendar on the website.

Overview NERTC Strategic Plan

Liz Carlton provided the update on the NERTC’s strategic planning session that was conducted during the last two executive committee meetings utilizing a SWOT analysis. The SWOT analysis identifies strengths, weaknesses, opportunities, and threats. The committee identified three top priorities and developed action plans for each priority. The priorities identified are as follows: 1. Increase participation and active involvement with the RTC and NE region Action plan:

o ITV meetings/panel discussion in conjunction with the executive committee face-to-face meetings

o Referral question for the month o host bi-monthly referral questions with an expert panel (i.e.

physicians, nurses, EMS)—suggested topics can include fluid resuscitation, CT scanning, TBI, air transport vs. ground transport

o regional discussion beneficial to providers and patients o Archive and pod cast on trauma website o Letter of invitation-we need to get people involved, peer pressure-

physician to physician 2. Performance Improvement Action plan:

o Formalize the PI structure to be used for RTTDC PI component o Review regional PI aggregate data (standing agenda item) & look at

things we can target to improve patient outcomes o Suggested indicators for review

# of times a patient is transported prior to arrival at definitive care

over and under triage mortality via ISS transport times scene times

o Monthly-bimonthly ITV PI meetings-question of the month idea o PI workshop

o Dedicated folks o Invitation to participate with key leadership individuals (i.e.

administrators, risk managers, PI managers) o Highlight model level III programs

o Needs as much energy and action as system development and patient management, these components are critical and work hand in hand

Comments made: we are rich in data, data is absolutely useless if nothing is done with it. 3. Education

o Continue TNCC, RTTDC, PHTLS o Include prehospital in PI workshop & physician panel o Hold ATLS course on bi-annual basis

o include midlevel providers o alternate locations

o PI education

EMS Medical Director’s Association Dr. James Longabaugh provided information on the newly formed Kansas EMS Medical Director’s Association, which will be directed under the Kansas Medical Society. The development of the Association was in response to the NHTSA assessment that was conducted a couple a years ago, which indicated that the State of Kansas needs more involvement from the EMS Medical Directors across the state. In addition, an EMS Medical Director Workshop was conducted last fall and is scheduled to be held on an annual basis. The KBEMS asked the association to develop a medical advisory committee that would advise them on topics as needed. To formalize the committee, language was introduced under SB262, which has passed. Eight members from the Association make up the advisory committee. The members of the Association have met several times by phone and the first face-to-face meeting is scheduled in Wichita next month. The committee has tentatively scheduled this year’s annual EMS Medical Director Workshop to be held in October. The goal of the association is to help advance EMS in the state, ensure that everyone is on the same page, help with protocol development of guidelines/standards, and in areas of the state where there is no medical direction, provide medical direction by reviewing and signing protocols. The NERTC scheduled an EMS Medical Director Workshop for the region this past fall. The executive committee viewed the regional workshop as an opportunity to provide information that was relevant to the NE region. Due to the minimal response, the workshop was cancelled. Bylaws Revision (Action) The proposed bylaw revisions included changing the way the officers of the executive committee are elected. The bylaw language suggested changes allowing the executive committee to vote on officers as opposed to the general membership electing the officers. Elaine Swisher, Lawrence Memorial Hospital, made the motion to approve the bylaws with the change. Dr. Deborah Smith, Jackson County EMS, seconded the motion. The motion passed. In closing The University of Kansas donated a registration to the Midwest Trauma Society meeting scheduled in May in Kansas City. A raffle was held. The winner of the registration raffle was Thomas Weidmaier, Providence Medical Center. Dr. Longabaugh reminded participants to sign the registration roster, complete the certificate of attendance and the meeting evaluation form. Dr. Longabaugh “thanked” St. Francis again for hosting the meeting and “thanked” everyone for attending. Adjournment The meeting adjourned at 4:10pm.

The EDand the

Management of Potential Organ

Donors

The EDand the

Management of Potential Organ

DonorsSt. FrancisApril 2010St. FrancisApril 2010

WHY IS DONATION IMPORTANT?

WHY IS DONATION IMPORTANT?

Joint Commission Initiativesto Increase Organ Donation

Every 12 minutes another name is added to the national waiting list

19 people will die waiting for an organ transplant every day

+1,000,000 people benefit from a tissue transplant each year

Every 12 minutes another name is added to the national waiting list

19 people will die waiting for an organ transplant every day

+1,000,000 people benefit from a tissue transplant each year

Who Is Midwest Transplant Network?

Who Is Midwest Transplant Network?

Midwest Transplant Network ServicesMidwest Transplant Network Services

• Incorporated in 1972 as the federally designated procurement agency for Kansas and the Western 2/3 of Missouri. > 300 Hospitals and Facilities

• Satellite OfficesColumbia, MissouriWichita, KansasJoplin, Missouri

• Incorporated in 1972 as the federally designated procurement agency for Kansas and the Western 2/3 of Missouri. > 300 Hospitals and Facilities

• Satellite OfficesColumbia, MissouriWichita, KansasJoplin, Missouri

HeadquartersHeadquarters

SatelliteSatellite OfficesOffices

Transplant Centers MTN Service Area

Transplant Centers MTN Service Area

Children’s Mercy Hospital (Liver, Kidneys, Heart Valves)KU Medical Center (Liver, Kidneys, Pancreas)Research Medical Center (Kidneys, Pancreas)St. Francis Hospital, WI (Liver, Kidneys, Pancreas)St. Luke’s Hospital (Heart, Kidneys)Univ. of MO Hospitals, Columbia (Kidneys)

Children’s Mercy Hospital (Liver, Kidneys, Heart Valves)KU Medical Center (Liver, Kidneys, Pancreas)Research Medical Center (Kidneys, Pancreas)St. Francis Hospital, WI (Liver, Kidneys, Pancreas)St. Luke’s Hospital (Heart, Kidneys)Univ. of MO Hospitals, Columbia (Kidneys)

Functions and ServicesMidwest Transplant Network


Coordination of organ,tissue, and eye donation including evaluation, procurement and allocation of organs and tissueProfessional education/consultation Donor family support services

Coordination of organ,tissue, and eye donation including evaluation, procurement and allocation of organs and tissueProfessional education/consultation Donor family support services



• Community education• Clinical laboratory, expert in

histocompatibility, molecular technology

• 24 hr. communication center to answer referral calls from our service area

• Community education• Clinical laboratory, expert in

histocompatibility, molecular technology

• 24 hr. communication center to answer referral calls from our service area

MTN ResponsibilitiesMTN Responsibilities

MTN’s Clinical Coordinators are Critical Care RNs and RTs with specialized training/certification in donor management they stay with the patient throughout entire caseMedical Director off site who assumes responsibility for the donor

MTN’s Clinical Coordinators are Critical Care RNs and RTs with specialized training/certification in donor management they stay with the patient throughout entire caseMedical Director off site who assumes responsibility for the donor

Referral: A Nursing InterventionReferral: A Nursing InterventionReferral of a potential donor is the single most important factor in increasing the supply of organs and tissue for transplantationMade within one hour after meeting clinical triggers1-800-DONOR 91

Referral of a potential donor is the single most important factor in increasing the supply of organs and tissue for transplantationMade within one hour after meeting clinical triggers1-800-DONOR 91

Success in the ER does matter!!Success in the ER does matter!!Pt: J.R. 30y/o M AA GSW to head and right armGCS: 14 in the field Deteriorated quickly in route to hospital.Pt arrived unresponsive in ERIntubated and placed on vent. CT for scan of head and spine. Stabilized by ER staff and imminent death referral made to MTN

Pt: J.R. 30y/o M AA GSW to head and right armGCS: 14 in the field Deteriorated quickly in route to hospital.Pt arrived unresponsive in ERIntubated and placed on vent. CT for scan of head and spine. Stabilized by ER staff and imminent death referral made to MTN

CT Head and NeckCT Head and Neck

Two gunshot wounds with bullet fragments, right subdural hematomas and intraparenchymal hemorrhages, pneumocephalus, right-to-left midline shift with cerebral edemaRadiopaque foreign body at the level of C6-7, no acute fractures or dislocations

Two gunshot wounds with bullet fragments, right subdural hematomas and intraparenchymal hemorrhages, pneumocephalus, right-to-left midline shift with cerebral edemaRadiopaque foreign body at the level of C6-7, no acute fractures or dislocations

Approximately 24 hours later pronounced Brain Dead, family

chose organ and tissue donation

Approximately 24 hours later pronounced Brain Dead, family

chose organ and tissue donation

Average BP in ER 122/59 (84), low 84/54Received 2000ml CrystalloidsStarted on Levophed to maintain BPK 3.2, glucose 240 (otherwise normal)ABG 7.19/36/397/13/-13Pt transferred to NSICU after 45 minutes

Average BP in ER 122/59 (84), low 84/54Received 2000ml CrystalloidsStarted on Levophed to maintain BPK 3.2, glucose 240 (otherwise normal)ABG 7.19/36/397/13/-13Pt transferred to NSICU after 45 minutes

Catastrophic Brain Injury GuidelinesCatastrophic Brain Injury GuidelinesCatastrophic Brain Injury Guidelines

Consider obtaining a critical care consult if not already involved in patient care Maintain SBP > 100 (MAP > 60)

1. Consider invasive hemodynamic monitoring 2. Adequate hydration: Ensure adequate hydration to maintain euvolemia 3. Vasopressor support: If hypotensive post adequate rehydration, utilize Neosynephrine as the first pressor of choice up to 2mcg/kg/min followed by Dopamine if needed

Maintain Urine Output > 0.5ml/kg/hr < 400ml/hr (consider DI if > 400ml/hr x2 hours) 1. Treat Diabetes Insipidus with Vasopressin drip 1-2.5u/hr, if UO still > 400ml/hr,

give DDAVP 0.5 mcg IVP every 2-3 hours 2. If UO falls below 0.5ml/kg/hr, assess fluid status-may need rehydration or BP

support Maintain PO2 > 100 & pH 7.35-7.45

1. Adequate ventilation: 5.0-8.0 PEEP aggressive respiratory hygiene if not contraindicated by patient’s condition (suction and turn every 2 hours) respiratory treatments to prevent bronchospasm Other orders to consider:

1. Monitor and treat electrolytes maintaining the following: Sodium: 134 – 145 mmol/L Potassium: 3.5 – 5.0 mmol/L Magnesium: 1.8 – 2.4 meq/L Phosphorus: 2.0 – 4.5 mg/dL Ionized Calcium: 1.12 – 1.3 mmol/L

2. Monitor glucose and treat with insulin drip if needed (keep 80-200) rather than

SQ 3. Monitor and treat Hgb/Hct/coagulation factors (especially if GSW or other

penetrating head injury) Maintain Hgb > 8.0 g/dL and Hct > 24% If PT > 18.0 give 2u FFP If Fibrinogen 70-100 give 2u FFP, if < 70 give cryoprecipitate If platelets < 50 give 6pk of platelets *remember to recheck labs after treatment

4. Maintain temp 36-37.5 Celsius with bair hugger/warming-cooling blanket

Catastrophic Brain Injury Guidelines Consider obtaining a critical care consult if not already involved in patient care Maintain SBP > 100 (MAP > 60)

1. Consider invasive hemodynamic monitoring 2. Adequate hydration: Ensure adequate hydration to maintain euvolemia 3. Vasopressor support: If hypotensive post adequate rehydration, utilize Neosynephrine as the first pressor of choice up to 2mcg/kg/min followed by Dopamine if needed

Maintain Urine Output > 0.5ml/kg/hr < 400ml/hr (consider DI if > 400ml/hr x2 hours) 1. Treat Diabetes Insipidus with Vasopressin drip 1-2.5u/hr, if UO still > 400ml/hr,

give DDAVP 0.5 mcg IVP every 2-3 hours 2. If UO falls below 0.5ml/kg/hr, assess fluid status-may need rehydration or BP

support Maintain PO2 > 100 & pH 7.35-7.45

1. Adequate ventilation: 5.0-8.0 PEEP aggressive respiratory hygiene if not contraindicated by patient’s condition (suction and turn every 2 hours) respiratory treatments to prevent bronchospasm Other orders to consider:

1. Monitor and treat electrolytes maintaining the following: Sodium: 134 – 145 mmol/L Potassium: 3.5 – 5.0 mmol/L Magnesium: 1.8 – 2.4 meq/L Phosphorus: 2.0 – 4.5 mg/dL Ionized Calcium: 1.12 – 1.3 mmol/L

2. Monitor glucose and treat with insulin drip if needed (keep 80-200) rather than

SQ 3. Monitor and treat Hgb/Hct/coagulation factors (especially if GSW or other

penetrating head injury) Maintain Hgb > 8.0 g/dL and Hct > 24% If PT > 18.0 give 2u FFP If Fibrinogen 70-100 give 2u FFP, if < 70 give cryoprecipitate If platelets < 50 give 6pk of platelets *remember to recheck labs after treatment

4. Maintain temp 36-37.5 Celsius with bair hugger/warming-cooling blanket

Catastrophic Brain Injury GuidelinesBuilding the FoundationCatastrophic Brain Injury GuidelinesBuilding the Foundation

Catastrophic Brain Injury GuidelinesBuilding the Foundation


Maintain Systolic BP > 100 MAP > 60

Consider invasive hemodynamic monitoringAdequate hydrationVasopressor support

Maintain Systolic BP > 100 MAP > 60

Consider invasive hemodynamic monitoringAdequate hydrationVasopressor support





Maintain Urine Output Between 0.5 ml/kg/hr - 3 ml/kg/hr

Consider DI if > 400 ml/hr for two hoursTreat DI with Vasopressin drip 1 – 2.5 u/hr

If UO continues to be > 400 ml/hr, give DDAVP 0.5 mcg IVP every 2-3 hours

If UO falls below 0.5 ml/kg/hour, assess fluid status

May need Hydration or BP support

Maintain Urine Output Between 0.5 ml/kg/hr - 3 ml/kg/hr

Consider DI if > 400 ml/hr for two hoursTreat DI with Vasopressin drip 1 – 2.5 u/hr

If UO continues to be > 400 ml/hr, give DDAVP 0.5 mcg IVP every 2-3 hours

If UO falls below 0.5 ml/kg/hour, assess fluid status

May need Hydration or BP support



Catastrophic Brain Injury Guidelines Building the FoundationCatastrophic Brain Injury Guidelines Building the Foundation

Maintain PO2 > 100Maintain pH 7.35-7.45Maintain adequate Ventilation

Peep 5-8Aggressive respiratory hygiene is not contraindicated by patient’s condition

Suction every two hoursRespiratory tx to prevent bronchospasms

Maintain PO2 > 100Maintain pH 7.35-7.45Maintain adequate Ventilation

Peep 5-8Aggressive respiratory hygiene is not contraindicated by patient’s condition

Suction every two hoursRespiratory tx to prevent bronchospasms



Monitor and treat electrolytesSodium 134-145Potassium 3.5-5.0Magnesium 1.8-2.4 Phosphorus 2.0-4.5Ionized Calcium 1.12-1.3

Monitor and treat electrolytesSodium 134-145Potassium 3.5-5.0Magnesium 1.8-2.4 Phosphorus 2.0-4.5Ionized Calcium 1.12-1.3



Monitor glucose and treat with insulin drip if needed rather than SQ

Keep between 80-200Monitor and Treat Hgb/HCT/Coags

HGB > 8.0 g/dLHCT > 24%PT < 18.0Fibrinogen > 100Platelets > 50

Maintain Normal Temperature36-37.5 CCan use bair hugger or cooling blanket

Monitor glucose and treat with insulin drip if needed rather than SQ

Keep between 80-200Monitor and Treat Hgb/HCT/Coags

HGB > 8.0 g/dLHCT > 24%PT < 18.0Fibrinogen > 100Platelets > 50

Maintain Normal Temperature36-37.5 CCan use bair hugger or cooling blanket

Reviewing J.R.’s stability at the beginning of organ donor management

Reviewing J.R.’s stability at the beginning of organ donor management

MAP 78UOP 700ml in last hourpH 7.43pO2 on 100% 467Levophed 8mcg/minNa 161, glucose 143

MAP 78UOP 700ml in last hourpH 7.43pO2 on 100% 467Levophed 8mcg/minNa 161, glucose 143

Success is measured with the recipientsSuccess is measured with the recipientsHeart: Ischemic Cardiomyopathy, 61 y/o MLungs: Cystic Fibrosis, 32 y/o FLeft segment of Liver:

Acute Failure, 1 month old MLiver: Chronic Failure, 41 y/o MRight Kidney: Lupus, 25 y/o MLeft Kidney/Pancreas: DM Type I, 37 y/o M

Heart: Ischemic Cardiomyopathy, 61 y/o MLungs: Cystic Fibrosis, 32 y/o FLeft segment of Liver:

Acute Failure, 1 month old MLiver: Chronic Failure, 41 y/o MRight Kidney: Lupus, 25 y/o MLeft Kidney/Pancreas: DM Type I, 37 y/o M

1

Slide 1KDHE Vision: Healthy Kansans living in safe and sustainable environments

Public Health Update

Northeast Kansas Trauma Region Annual Meeting

Jason Eberhart-Phillips, MD, MPHState Health Officer and Director

of Health, KDHE

A Whole New Kind of Flu• Global emergence of an

entirely new flu virus • By sheer luck this virus is

not usually a killer– 100 times less lethal

than the 1918 flu virus• Still, by mid-March 2010

– 60 million cases in US– Approximately 270,000

hospitalizations– > 12,000 deaths

The “Third Wave” Never Came Herd Immunity In Action

Vaccine: A Huge Success• In just over three

months >889,000 vaccine doses were distributed in KS!– An unprecedented

statewide mobilization– Every local health

department in the lead– >1000 private providers– Thousands of volunteers

staffing public clinics

Kansas Vaccine Uptake

2


Luck Has Been on Our Side…• Disease virulence is low• Virus is genetically stable• Transmissibility is high, but

could’ve been higher• Vaccine induces a strong,

fast, immune response• Most people require only a

single dose of vaccine• It is as safe as expected


…Most of the Time!• Predictions of ample

vaccine supplies were overly optimistic– Up to 160 million doses

expected by October 31– Received less than 30

million– One of the poorest

producing vaccine virus strains ever seen

– Just 0.2 - 0.6 doses/egg


Statewide Clean Indoor Act• Kansas is now the

40th state to assure protection from second hand smoke in public places– Implementation now

underway– Educating businesses– KsSmokeFree.Org


Primary Seat Belt Law• Carry over bill (HB

2130) passed by the Senate

• May yet be approved by the House

• Over $10 million in one-time federal funds incentive for the state


KDHE Bills• SB 62 passed and signed –

implements new standard TB screening process for all Kansas post secondary educational institutions

• SB 62 includes SB 147 which implements an “opt out” process for universal screening of pregnant women for HIV infection


More KDHE Bills• SB 488 authorizes criminal background

checks for KDHE employees with access to sensitive birth and death data

• Bill includes SB 448 – recommended by the Blue Ribbon Panel on Infant Mortality – which authorizes research related to causes of infant mortality based on birth certificate information

• Hung up currently in conference

3


More KDHE Bills• SB 531 establishes a certification

program for contractors who perform testing and remediation for radon in residential settings: PASSED

• SB 499 would set standards for healthy foods in school vending machines– Was heard in Senate Education Committee,

but no action was taken


More KDHE Bills• SB 505 Menu labeling

for chain restaurants• Had informational

hearing in Senate Public Health and Welfare Committee

• Similar requirements were included in the national health care reform legislation, so no action is needed in KS


Other Bills of Interest• HB 2356 now includes

content from SB 447 • Sets new supervision

standards for day care • Requires inspection of

registered day care homes• And development of a risk-

based system to determine frequency of inspections for child care facilities


Other Bills of Interest• HB 2596 would have

limited KDHE regulations for lead based paint contractors who repair or renovate houses built before 1978

• Compromise was achieved, making changes in the regulations for the program so that the bill did not go forward


www.kdheks.gov

To Protect the Health and Environment of all Kansans To Protect the Health and Environment of all Kansans by Promoting Responsible Choicesby Promoting Responsible Choices

1

Our Vision - Healthy Kansans living in safe and sustainable environments

NE Regional Trauma Council General Membership Meeting


2010 Trauma System Update

Rosanne Rutkowski, RN, MPHKansas Trauma Program [email protected]


Welcome & Thank You!

Update on State Priority projects Level IV

Federal Trauma Care & Health Care Reform

Regional Education Regional Trauma Plan


Goals of the Kansas Trauma System

Reduce the number of preventable deaths Improve outcomes for traumatic injuries Encourage provider preparation and response to

trauma Reduce medical costs through appropriate use of

resources Increase public awareness & prevention Design an inclusive and comprehensive system Develop trauma education resources

Kansas Trauma Plan 2001


State Trauma Program: Infrastructure

KDHE: Lead Agency Regional Trauma Councils Advisory Committee on Trauma Trauma Registry Trauma Center designation

Advisory Committee on Trauma Appointed by the Governor's office

Regional Trauma Councils Hospitals- administrators, physicians, nurses EMS Public Health Departments


Projects: 2009

Level III trauma center grants Developed Level IV criteria Updated Regional Trauma Plans Updated Data Benchmark Report 2009 Annual Report & newsletter 1st State EMS Medical Director’s Conf. Listserv and Report Writer Training

2

Our Vision - Healthy Kansans living in safe and sustainable environments Our Vision - Healthy Kansans living in safe and sustainable environments


State Designated Trauma Centers:

Level I Trauma Centers University of Kansas Hospital Via Christi- St. Francis Wesley Medical Center

Level II Trauma Centers Overland Park Regional Medical Center Stormont Vail Regional Health Center

Level III Trauma Centers Labette Health Via Christi- Pittsburg



Projects 2010

Priority Assessment- 5/2010 Update regulations to include Level IV

trauma center Cont. Level III trauma center grants Update state trauma registry system On-line training

Develop interface EMS/trauma Data Awarded CDC Funding for field triage


Proposed Level IV criteria:

Trauma Team Education requirements Physician- ATLS ER Nurse- TNCC

Trauma Team Activation Plan On call schedule Equipment for resuscitation Quality improvement program Transfer protocol

3


Trauma/EMS Interface

Board of EMS & KTP awarded a grant from KDOT to support interface

6-8 months completion EMS Data will be downloaded into the

trauma registry 2 data elements will be provided back

to EMS


Trauma/EMS Data Interface


Training & Education:

Establish min. standards for trauma care Prehospital PHTLS

Nurses TNCC

Physicians ATLS

Hospitals Rural Trauma Team Development (RTTDC)


Trauma Education Needs Survey

Trauma Education Funding Sources: Kansas Rural Health Options Project (KRHOP) Regional Trauma Councils Christopher & Dana Reeves Foundation Grant-

applied for

KRHOP Funds: RTTDC, ATLS, PHTLS, TNCC $1,500 RTTDC $1,000 PHTLS $1,500 TNCC $1,000 ATLS scholarships ( 20)

Outcome?


100.0%95.8%160167Total

11.9%95.0%1920SW

11.9%95.0%1920SE

30.0%98.0%4849SC

11.9%95.0%1920NW

23.8%92.7%3841NE

10.6%100.0%1717NC

Respond‐ingTotal

% of All Respond‐ing

Response Rate

# of EMS Services*

Region

Response Totals by Region

*Represents all Critical Access Hospitals, and acute care facilities providing trauma services.

100.0%100.0%127127Total

14.2%100.0%1818SW

11.0%100.0%1414SE

24.4%100.0%3131SC

14.2%100.0%1818NW

26.0%100.0%3333NE

10.2%100.0%1313NC

Respond‐ingTotal*

% of All Respond‐ing

Response Rate

# of Hospitals

Region


EMS/Hospital Survey Response


# Needing ATLS Training

51

188

48 37 49

127

0

50

100

150

200

250

300

NC NE NW SC SE SW

% Needing ATLS Training

63.0%54.5%

63.2%

41.6%

60.5%50.2%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

NC NE NW SC SE SW

Need for ATLS

MD, PA, ARNP providing ED coverage as primary care provider: Total Number 345# w/ ATLS: 157, #needing ATLS: 188 ( 55% need ATLS)

4


# Needing TNCC Training

91 83

166136

65

297

0

50

100

150

200

250

300

NC NE NW SC SE SW

% Needing TNCC Training

32.3%48.7%

28.6%34.9%31.7%

45.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

NC NE NW SC SE SW

Need for TNCC

RN, LPN providing care in ED, Total 938# w/ TNCC: 641, # needing 297 (32% need TNCC)


# Needing PHTLS Training

1146

294192

784

308303

0

200400

600800

10001200

1400

NC NE NW SC SE SW

% Needing PHTLS Training

80.8% 77.4%

60.3% 61.5%51.8%70.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

NC NE NW SC SE SW

Need for PHTLS

Attendants( 1st responders, EMTs, Paramedics) providing care in your service Total: 1638# needing PHTLS: 1146, # w/ PHTLS; 492 ( 70% need PHTLS)


TNCC Requirement: NE33 Hospitals

No: 1236%Yes: 18

55%

Don't know 39%


TNCC Requirement: Statewide 127 hospitals

No: 5342%Yes: 69

54%

Don't know: 54%


ATLS Requirement: NE 33 hospitals

No: 1855%

Don't Know 721%

Yes: 824%


ATLS Requirement: Statewide 127 Hospitals

Don't Know: 2016%

Yes: 3326%

No: 7458%

5


1604518NW

12621425NC

16384332NE

3132539SW

2143620SE

5412235SC

ATLSRTTDCTNCCPHTLS

RTC- Trauma Education 2009


CDC Field Triage Implementation Project

Awarded funding from CDC Kansas, Massachusetts, Michigan

Goal: Pilot Field Triage Guidelines in state/region

9-member leadership team SE Regional Trauma Region will serve

as pilot area


Field Triage Decision

Scheme: The National

Trauma Triage Protocol



Federal: Health Care Reform


Health Care Reform

Emergency & Trauma Care Systems Support regionalized, coordinated and

accountable emergency care Funds appropriated FY11 for research in

emergency medicine & regionalized emergency care systems

Mandate & fund integrated trauma system development Establishes new trauma center program to

strengthen ED & trauma center capacity

6


Regional Trauma Council Funding2009

54%

26%

1%15%

4%

0%

Education: Prevention: Meetings: PI: Administration EMD


NE Regional Trauma Council 2009 $23,472

Administration:$1,3586%

Meetings: $1,450 6%

Prevention: $3,000 13%

Education: $17,520 75%

Education: $17,520 Prevention: $3,000Meetings: $1,450 Administration:$1,358


NE RTC Budget: 2010

Education: $8,900Admin. : $1,358Prevention: $6,000Meetings: $2,550PI: $1,300Other: $ 14

Total: $20,121


Regional Trauma Plans

Regional Plans Reviewed & Updated:2005, 2007, 2009

2009 Recommendations Tailor & adopt CDC field triage guidelines Support trauma education assessment Injury prevention based on trauma data Identify a legislative liaison in ea. region Include executive summary in future

plans


Regional Trauma Councils

Cornerstone of the state system An opportunity for input into the state system Opportunity to become involved at regional level Responsible for assessing regional resources Responsible for identifying educational needs and

then providing education Responsible for community prevention efforts


Kansas Trauma Program

Web site: www.kstrauma.org ACT Regional Trauma Council Education Regulations Publications Contact information Newsletter

7


Kansas Trauma Program StaffRosanne Rutkowski, RN, MPHProgram Director

Dan Robinson, MBAAssistant Program Coordinator

Dee Vernberg, PhD, MPHTrauma Epidemiologist

Jeanette ShipleyRegional Trauma Coordinator

Dan RussellDatabase Administrator


Thank you for your support

End Points of Resuscitation in the Trauma Patient

Charles Richart, MD, FACS,FCCM

SHOCK

• Shock is cardiovascular collapse– Systemic hypoperfusion owing to

reducation either in cardiac output or in effective circulating blood volume

– End results=hypotension followed by impaired tissue perfusion and cellular hypoxia

Physiology

• Systemic tissue perfusion– Determined by Cardiac Output (CO) and

systemic vascular resistance (SVR)

– CO= HR x SV• Stroke volume is related to preload, myocardial

contractility, and afterload

• SVR= vessel length, blood viscosity, inverse vessel diameter

Stages of Shock

• Nonprogressive phase / Preshock– Warm shock or Compensated shock

– Compensatory mechanisms are activated• Baroreceptor reflexes release catecholamines,

activate renin-angiotension axis, ADH

– Perfusion of organs is maintained

Stages of Shock

• Progressive Stage– Compensatory mechanisms are overwhelmed

– Tissue hypoperfusion and onset of worsening circulatory and metabolic imbalances

• Widespread tissue hypoxia

• Persistent Oxygen deficit, proceeded by anaerobic metabolism, which will cause lactic acidosis

• Microcirculation becomes stagnant at times, causing pooling, increasing hypoxic injury and risk of DIC

Stages of Shock

• Irreversible Shock / End-Organ dysfunction– Occurs after the body has sustained cellular

and tissue injury so severe hemodyanmic or organ recovery is impossible.

– Myocardial contractility worsens

– MODS

– Death

Hypovolemic Shock

• Loss of blood volume and oxygen carrying red blood cells resulting in inadequate oxygen delivery to tissues– Hemorrhage induced or fluid loss induced

• Estimate of patient’s circulating blood volume:– 7% of body weight=total blood volume (TBV)

• 70kg x .07= 4.9 L TBV

• During hemorrhage interstitial fluild shifts to intracellular and intravascular space– This will dilute RBC’s and decrease H/H

Causes Hypovolemic Shock

• Internal Bleeding• Pancreatitis• Trauma• Surgery• Fracture

– Estimated blood loss from fractures

• Rib=100mL• Humerous=250mL• Tib/Fib=250-500mL• Femur=1000mL• Pelvis=500-3000 mL

Assessment of Hypovolemic Shock

• Lab: decrease H/H, serum Na+ could increase with hypertonic solutions, decrease potassium and calcium, decrease Platelets

• Neuro: c/o thrist, lethargic, dilated but reactive pupils

• GI/GU: decrease UO due to aldosterone and ADH release, urine Na+ may decrease, can go into ARF/ATN

Assessment of Hypovolemic Shock

• Cardiac: decrease peripheral pulses• Lungs: tachypnea• Skin: decrease temperature, pale• Hemodynamics:

– Increase HR– Decrease PCWP (preload), decrease CVP– Decrease CO (pump function)– Increase SVR (afterload)– Decrease BP– Increase respiratory rate– Decrease UO

Treatment of Hypovolemic Shock

• Find and control bleeding or fluid loss• Need large bore IV’s to give fluid quickly• Replace lost fluid: LR 3:1 ratio

– 3mL of LR for every 1mL of EBL

• Give blood if severe/profound shock– Hct <28% (Hct <30% with elderly)

www.emsprime.com/images/Shock.png

Reliability of FAST

• Meta-analysis of 62 studies with over 18,000 total scans performed

• Pooled overall sensitivity 79% • Pooled overall specificity 99% • Overall bias-adjusted sensitivity is low in

FAST

Stengel, et al. Association between Compliance with Methodologic Standards of Diagnostic Research and Reported Test Accuracy: Meta-analysis of Focused Assessment of US for Trauma. Radiology, 2005; 236:102.

Reliability of FAST

• Penetrating anterior chest trauma • 32 patients, 65% stab wounds, 35% GSW • 100% sensitivity and specificity for pericardial effusion• 100% sensitivity and specificity for intraperitoneal fluid • FAST effective guide for surgical decision making in

anterior penetrating chest trauma

Tayal, et al. FAST (Focused Assessment With Sonography in Trauma) Accurate for Cardiac and Intraperitoneal Injury in Penetrating Anterior Chest Trauma. J Ultrasound Med 2004; 23:467-472.

Base Deficit

• 2069 trauma patients admitted to ICU• Worsening base deficit = mortality of 45% in patients

with BD > 6• Incr in BD directly assoc with decr SBP, incr PT, incr in

HR and lactate levels as well as mortality with p<0.0001• BD > 10 also was noted to be assoc with higher

transfusion requirements (14 units PRBCs) • BD may guide early and aggressive resuscitation

Rixen, D, et al. Base deficit development and its prognostic significance in posttrauma critical illness: An analysis by the trauma registry of the Deutsche Gesellschaft fur Unfallchirurgie. Shock 2001; 15 (2) : 83-89.

Base Deficit

• 3791 trauma patients admitted with ABG in first 24 hours

• Matched on mechanism, TRISS, age, etc.• Most (80%) had base deficit• Age < 55, no head injury and BD -15 assoc with 25%

mortality• Age 55 with no head injury OR Age <55 with head injury

25% mortality for BD -8

Rutherford, E, et al. Base Deficit Stratifies Mortality and Determines Therapy. J of Trauma 1992 Sept; 33(3) : 417-423.

Coagulopathy

• 40% of trauma fatalities are due to hemorrhagic shock, most are coagulopathic at death

• Hypothermia, Acidosis, Coagulopathy – “Lethal Triad”

• DIC “Death Is Coming”– In severe hemorrhage, elevated INR, PT, PTT with

thrombocytopenia and low fibrinogen

Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J of Trauma 1995; 38 : 185-193.

Coagulopathy

• Why? • We worsen coagulopathy by DILUTION

– Dilution of coagulation factors

– Calcium used in activation and not replaced

• We DILUTE with COLD fluids• Acidosis is present and worsening as long as tissue

hypoxia present, i.e. we don’t get CONTROL of bleeding

Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J of Trauma 1995; 38 : 185-193.

Coagulopathy

• How do we promote coagulation in massive hemorrhage/ massive transfusion?

• Novo 7 (recombinant VIIa)– Still controversial

• Thrombin, GelFoam, Surgicel and similar products• UT Houston study Trauma Mortality, the Lethal Triad and Massive

Transfusion– Fixed Acidosis and Hypothermia– Behind on blood products– Recommendation of EARLY FFP and FFP to PRBC ratio 1:1 in

massive transfusion

Gonzalez E, Moore FA, et al. Fresh frozen plasma should be given earlier to the patient requiring massive transfusion. J of Trauma 2007; 62 (1) : 112-119.

Recombinant VIIa

• Although controversial, recent data out of Iraq • Combat casualty patients, ISS >15 and required massive

transfusion (10 units/ 24 hrs) • 49 received VIIa

– 24 hr mortality 7 of 49 (14%)– 30 d mortality 15 of 49 (31%)

• 75 did not receive VIIa– 24 hr mortality 26 of 75 (35%)– 30 d mortality 38 of 75 (51%) p=0.03

Spinella P, Perkins, J, et al. The Effect of Recombinant Activated VII on Mortality in Combat-Related Casualities With Severe Trauma and Massive Transfusion. J of Trauma 2008 Feb ; 64 (2) : 286-294.

Fluid Resuscitation

• What type and when? Also controversial• Smaller volume resuscitations using hypertonic saline

– Patients requiring massive transfusion– Prevent complications like ARDs, studies are ongoing– Delayed vs Immediate Resuscitation

• Isotonic Warm Fluids are certainly the standard of care• Ratios of resuscitation are also changing

– 3:1 and DaNang lung– 1:1:1, 1:2 for blood/FFP/platelets

• Emergent availability of FFP

Holcomb et al. J of Trauma 2006 Feb ; 62 (2) :294-310

Gutierrez G, Reines D. Clinical Review: Hemorrhagic Shock. Crit Care. Apr 2004 8(5): 373-381.

Krausz M. Initial resuscitation of hemorrhagic shock. World J Emer Surg 2006 1:14.

Fluid Resuscitation

• Currently recommendations are still crystalloid (LR/ NS) as initial fluid

• Transfusion is not recommended unless there is FAILURE to respond to 2 liters of crystalloid WITH suspected hemorrhage– More studies accumulating that demonstrate that

transfusion except in the massive transfusion setting has significant morbidity and mortality

– Increased tolerance of anemia • Resurgence of Interest in Whole Blood for Massive

Transfusion

Holcomb et al. J of Trauma 2006 Feb ; 62 (2) :294-310

Gutierrez G, Reines D. Clinical Review: Hemorrhagic Shock. Crit Care. Apr 2004 8(5): 373-381.

Endpoints of Resuscitation

What does “Endpoints of Resuscitation” mean?

AMA?

Resident 80 hour work week?? “Ideal” Endpoint of Resuscitation

• Marker of the presence of SHOCK – at the earliest stages

• Ensures that resuscitation is complete – normalization of the endpoint


• Severely Injured Trauma Patients- High risk for multiple organ dysfunction syndrome (MODS)

- Death

• Maximize Chances for Survival– treatment modalities – must focus on:

Resuscitation from shock- Rapid hemostasis - Appropriate fluid resuscitation


• Shock - inadequate tissue oxygenation to meet tissue O2 requirements

• Leads to anaerobic metabolism – results in metabolic acidosis

• Depth and duration of shock – cumulative oxygen debt


• Resuscitation is complete, when:1. Oxygen debt is repaid2. Tissue acidosis eliminated3. Normal aerobic metabolism is restored


• Patients may appear to be adequately resuscitated based on normalization of vital signs

• --- But may have occult hypoperfusionand ongoing tissue acidosis

May lead to organ dysfunction and death

Use of “Endpoints” may allow early detection and reversal of

this state

Hemostasis – First!!!

Uncontrolled Hemorrhage

Fluid Resuscitation• No Fluid Resuscitation – may lead to death• Aggressive Fluid Resuscitation – may lead

to more bleeding – “pop the clot”• “Limited” (or “hypotensive” or “delayed”)

Fluid Resuscitation – may be beneficial

Uncontrolled Hemorrhage

Controversial – Aggressiveness of IVFs in hypotensive patient with suspected uncontrolled hemorrhage – before surgical control

• May increase amount and rate of bleeding• Uncorrected severe hypotension

- May lead to death- If TBI – Secondary brain injury - Risk of post-operative organ failure

Fluid Resuscitation in Uncontrolled Hemorrhage

• Shaftan, Surgery 1965; 58:851-856 – Dog model – aggressive fluid resuscitation with uncontrolled arterial bleeding, led to increased amount of bleeding


• Capone, J Am Coll Surg 1995;180:49-56 – Rat model – uncontrolled hemorrhage, attempts to achieve normal MAP – increased bleeding and mortality, while hypotensive resuscitation improved survival

• Several studies – Uncontrolled bleeding from spleen, there was increased bleeding and mortality – with vigorous infusion of crystalloids.


• Bickell, et al, October 1994 NEJM• “Immediate versus Delayed Fluid

Resuscitation for Hypotensive Patients with Penetrating Torso Injuries”

• Lower survival in patients who received fluid resuscitation before surgical control of bleeding, versus patients receiving delayed fluids in the OR (62% vs 70%)

Hypotensive Resuscitation during Active Hemorrhage: Impact on In-Hospital Mortality

Dutton, R., et al; Journal of Trauma, Vol. 52(6). June 2002. 1141-1146

• Clinical trial – patients with initial systolic BP < 90 mmHg – evaluated role of titration of the initial resuscitation fluid to a systolic BP lower than normal (systolic BP < 70 mmHg) vs normal (syst BP > 100 mmHg)

• Mortality same• Concluded – titration of initial fluid therapy in

hypotensive trauma patients to lower than normal BP – during active bleeding – did noteffect mortality

Conclusions – Resuscitation of Hypotensive Trauma Patients

• Aggressive fluid resuscitation – with uncontrolled hemorrhage – increases bleeding and mortality

• “Controlled hypotension” – may prevent worsening of bleeding associated with aggressive fluid resuscitation – while preventing cardiac arrest or organ failure – secondary to tissue hypoperfusion

• Optimal MAP may be 60-80 mmHg

Endpoints of Resuscitation Advanced Trauma Life Support (ATLS)

• Standard of Care – Markers of “successful”resuscitation include the restoration of NORMAL:

1. Blood Pressure2. Heart Rate3. Urine Output

> 0.5 cc/kg/hr – Adult > 1.0 cc/kg/hr – Child

• If these remain abnormal – clear that need further resuscitation

Classes of ShockClassClass Blood Blood

LossLossRespondResponderer

CNSCNS BPBP PulsePulse/RR/RR

UrineUrine TXTX

Class IClass I 750cc750cc

15%15%YesYes Slightly Slightly

anxiousanxiousNLNL <100<100 3030

cc/hrcc/hrIVFsIVFs

Class IIClass II 750750--1500cc1500cc

1515--30%30%

YesYes Mildly Mildly anxiousanxious

NLNL >100>100 2020--3030

cc/hrcc/hrIVFsIVFs

? blood? blood

Class IIIClass III 15001500--2000cc2000cc

3030--40%40%

Transient or Transient or nonnon--responderresponder

ConfuseConfused d AnxiousAnxious

Mod Mod decreasdecreaseded

>120>120 55--1515

cc/hrcc/hr

IVFsIVFs

BloodBlood

OperationOperation

Class IVClass IV >2000cc>2000cc

> 40%> 40%

NonNon--responderresponder

LethargiLethargicc

MarkedlMarkedly y decreasdecreaseded

>140>140 NegligNegligibleible

Rapid Rapid IVFsIVFs

BloodBlood

OperationOperation

Hypovolemic Shock

Rapid ResponseRapid Response Transient ResponseTransient Response No ResponseNo Response

VITAL SIGNSVITAL SIGNS Return to normalReturn to normal Transient Transient improvementimprovement

Recurrence of BP/HRRecurrence of BP/HR

RemainRemain

AbnormalAbnormal

EstimatedEstimated

Blood LossBlood Loss

MinimalMinimal

(10 (10 –– 20 %)20 %)

Moderate and Moderate and ongoingongoing

(20 (20 –– 40 %)40 %)

Severe Severe

( > 40 %)( > 40 %)

Need MoreNeed More

CrystalloidCrystalloid

LOWLOW HIGHHIGH HIGHHIGH

Need More Need More

BloodBlood

LOWLOW MODERATE to HIGHMODERATE to HIGH IMMEDIATEIMMEDIATE

Need Need Operative Operative InterventionIntervention

POSSIBLYPOSSIBLY LIKELYLIKELY HIGHLY HIGHLY

LIKELYLIKELY

Advanced Trauma Life Support (ATLS) –(Con’t)

• After normalizing the above parameters – up to 85% of severely injured trauma patients –have inadequate tissue oxygenation (occult hypoperfusion) – based on ongoing metabolic acidosis or gastric mucosal ischemia (compensated shock)

• ***Recognizing this state – with better “markers” – and rapid reversal – minimize risk of MODS or death

• Use of “endpoints” may allow early detection and reversal of this state


•Global Endpoints •Regional (Organ-Specific) Endpoints

Global Endpoints

• Blood pressure• Heart rate• Urine output• Mental status• Capillary refill • Pulse Pressure• Base deficit/pH• Serum lactate levels• Oxygen delivery/consumption

Arterial Base Deficit

• Higher Base Deficit – associated with lower blood pressure on admission, greater blood loss, and greater fluid needs

• Normal range of “Base Deficit” – (- 3 to + 3mM)

• Mild (BD – 2-5), Moderate (BD – 6-14), Severe – BD > 14)

• Base deficit – correlates with mortality • BD > 6 – marker for severe injury

Arterial Base Deficit (con’t)

• Increasing base deficit – 2/3 ongoing blood loss

• Increase BD – instability, transfusions, coagulation abn, risk of death, length of stay, acute lung injury

• BD > 8; 25% mortality• BD > 15; 70% mortality• Serial Base Deficits – document clearing

Arterial Lactate

• Time to normalize lactate – important prognostic factor

• Normalized 24 hours – all survived• Normalized 24-48 hours – 25% mortality• Not normalized 48 hours – 86% mortality• Lactate > 2.5mM at 12 hours post-injury

predicted onset of multi-organ failure

• Not readily available in all institutions

Pulmonary Artery Catheter

• Commonly used in ICU setting• PCWP – approximates Left atrial pressure,

which approx. left ventricular end-diastolic pressure (LVEDP) – which reflects LVED Volume, which correlates with contractility

Pulmonary Artery Catheter

• Assumptions• Inconsistent relationship – between PCWP

and Cardiac Output – acute lung injury, high ventilator pressures, poor pulmonary compliance, and/or hemodynamically unstable

Esophageal Doppler Monitor (EDM)

• Small caliber Doppler ultrasound probe –esophagus – measures the mean velocity (Vm) of blood flow in descending aorta

• Cardiac output and preload assessment –regardless of the level of mechanical ventilation

• CO calculated by computer – using aortic diameter – estimated by nomogram

• Doppler waveforms – calculates flow time –measures cardiac preload and peak velocity –measures cardiac contractility

Invasive Monitoring

• Scalea (J. Trauma 1990 Feb; 30 (2): 129-134) – Instituted protocol for early invasive hemodynamic monitoring of high risk geriatric blunt trauma patients (severe injuries)

• Identified occult shock early • Optimized pts. - volume, inotropes, and

afterload reduction – as needed• Helped prevent MODS and death

Determinants of O2 Delivery

• Cardiac Output– HR X S.V.

• Arterial O2 Content = CaO2– [Hb x 1.39 x SaO2] + [PaO2 x 0.0031]

• DO2 (O2 Delivery)– C.O. x CaO2 x 10

Oxygen Delivery

• Shoemaker – evaluated high risk surgical patients who survived – found they had significantly higher O2 delivery and cardiac index (CI - > 4.5 L/min/m2); (O2 delivery was > 600 mL/min.m2) and (oxygen consumption > 170 mL/min.m2)

• Goals for Resuscitation – to improve survival • Maximizing O2 delivery – volume loading,

dobutamine infusion if necessary, and blood transfusions to hemoglobin of 14

• Supranormal levels of CI, DO2, and VO2 – improvement in survival and decrease in organ failure rates

• If did not reach goals by 12 hours – increased risk of MODS

Oxygen Delivery (con’t)

• Durham, Journal of Trauma 1996;41 -Resuscitation to O2 delivery and consumption parameters defined by Shoemaker - did not improve rate of MODS or death

• ***Predictors of outcome – not endpoint of resuscitation

Mixed Venous Oxygen Saturation (SvO2)

• Reflects adequacy of O2 delivery to tissues – in relation to global tissue O2 demands

• Normal – SvO2 = 75%• Normal – PvO2 = 40 mmHg• Central venous oxygen saturation = ScvO2• If ScvO2 < 70% - tissue hypoperfusion

Regional Endpoints

• Gastric tonometry – gastric ischemia• Tissue oxygen monitoring• Brain oxygen monitoring• Near Infrared Spectroscopy (NIRS) –

regional cellular oxygenation

Gastric Tonometry

• If systemic perfusion decreases – shunting from some organs (skin, muscle, kidneys, and gut) to preserve flow to brain and heart

• If the sub-clinical ischemia to organs could be identified – these are the patients that need additional resuscitation despite seemingly normalized vital signs

Gastric Tonometry

• Gastric tonometry (tonometric nasogastric tube – gas permeable silastic balloon filled with saline as a tonometer) – based on the finding that tissue ischemia leads to an increase in tissue PCO2, and subsequent decrease in tissue pH.

• Gastric Mucosal pH• Intramucosal pH (pHi) – calculated based

on Henderson-Hasselbach equation

Gastric Tonometry

• pHi – correlates with sepsis score• pHi < 7.32 – mortality rate of 37%• pHi > 7.32 – all survived• pHi < 7.32 – good predictor of MODS and

mortality• Technological limitations – manual

technique – using semi-permeable balloon is cumbersome

Near Infrared Spectroscopy (NIRS)

• Method of monitoring hemoglobin O2 saturation in tissue (StO2)

• Non-invasive and continuous method for monitoring adequacy of resuscitation – in terms of normalizing tissue oxygenation

• Skeletal muscle StO2 (transcutaneous probe) –tracks systemic O2 delivery, with improved StO2 with resuscitation

• Potential for NIRS to monitor tissue perfusion and guide resuscitation

• What should be done on a daily basis? • Multi-system injured trauma patient –

involved in MVC – Hypotensive at scene, arrives in the ED in shock, and admitted to the OR and/or ICU

• How should we resuscitate and monitor the patient’s response, to avoid MODS and death???

• Pre-hospital, ED, OR and ICU

Discussion

Pre-Hospital Endpoints

• Blood Pressure (MAP) – Dynamap- Monitor continuously- Maximize BP for patients with brain injury- Resuscitate to lower limits of normal with penetrating injuries

• Pulse Oximetry - Oxygen saturation – to optimize in pre-hospital setting

Emergency Department Endpoints

• Monitor response to resuscitation – ATLS • ABGs – Base Deficit – severity of shock

and adequacy of resuscitation • Lactate levels

OR and ICU

• Ensure clearance of Base Deficit• Pulmonary Artery Catheter (PCWP)• Organ Specific Resuscitations – (ie- TBI)• Tissue oxygen and metabolic indicators• Near Infrared Spectroscopy (NIRS)• Esophageal Doppler monitoring

What is the “True”Endpoint of

Resuscitation????

Case Presentation

• JW is a 53 year old AAM• Found down less than 12 blocks from SLH after

sustaining a GSW to the abdomen at approx 2046• 2058 EMS arrived on scene• 2103 Pt with agonal respirations and unresponsive

orally intubated in the field, 2 16G IVs placed• VS recorded by EMS

• 2108 60/40 60 6 84% • 2112 54/38 118 18 86%

Case Presentation

• 1800 mL in crystalloid given prior to arrival • 2112 Arrival as Level I Activation

– 108/35 HR 77

– 72/42 HR 68

– 102/77 HR 63

– 30/11 HR 63

• Pt received additional 4 liters crystalloid and one unit PRBC in bay

Case Presentation

• After the initial drop in SBP, FAST exam was performed, NEG

• Abd soft, non-distended• Wound was locally explored appearing to track

superficially • CXR, KUB, Central lines, Labs, and Foley were obtained.

Pt also received Ancef and Tetanus.– 2 cm metallic fragment at level of L1/L2 and two smaller

fragments lower in abd• 2135 After the second drop in SBP the pt was taken

emergently to the OR

Case Presentation

• 2140 Hb 6.7 Plts 210 INR 1.4 CO2 16 ICa 4.2 • CellSaver was operational prior to skin incision• Massive amount of intrabdominal blood present, greater

than 3.5 liters • Aortic tamp required to maintain a blood pressure and

pulse while on 3 pressors and receiving massive transfusion

• Right colon perforation, hilar injury to the right kidney

Case Presentation• 2240 6.98 / 56 / 322 / 12.4 / -18.3

– Lactate 6.8, ICa 5.5, Hb 8.8

• 2228 INR 6.3 PT 58.3 PTT >200 Plt 44 FIBRINOGEN 47

• 2320 7.06 / 57 / 378 / 15.5 / -13.3 – Lactate 6.8, ICa 2.1, Hb 4.8

• 0001 6.94 / 75 / 344 / 15.2 / -15.7– Lactate 7.7, ICa 2.5, Hb 6.1

• Damage control was performed and the pt continued to ooze continuously

Case Presentation

• Pt was transfused with – 9 units PRBCs in OR– 1 unit PRBCs in ER– 1525 mL of recovered PRBCs from CellSaver– 4 units FFP – One single donor unit platelets

• Additional agents to pressors and antibiotics included – 4 liters crystalloid– 2 grams of Calcium chloride– 3 amps of Sodium bicarbonate

Case Presentation

• Ultimately when all visible sources of bleeding were controlled hemostatic agents were employed – Gel Foam – Evisel– Thrombin – Novo 7, ordered, not administered

• The patient had no sustainable blood pressure without aortic tamp in place and continued to ooze

• 0002 The patient was declared dead

17 y/o Male – Bicycle vs Car

Scene – 2300 • Found 50 feet from bicycle• GCS – 3 • BP – 80/palp• Pulse – 72 • Deformity of right femur

Management at Scene

Scene – Tx

1. Intubation2. Establish IV 3. IVFs – 750 cc4. Splint femur fracture

ED Evaluation – 2030

• Temp – 36.5• BP – 139/91• Pulse – 87• GCS – 6 • 97% O2 sats• IVFs/Urine = 1000cc/150cc• Hb – 12.6

ED Management

Priorities

• Avoid hypoxemia and hypercarbia –Intubation and ventilation

• Maintain adequate perfusion –“Euvolemia”

• Avoid secondary brain injury• Disability – evaluate for need for

craniotomy;

Resuscitation

• Admit ED – 2030• Volume Resuscitation – ED = 1000cc;

Urine output – 150cc• ED – 2050 – BE = (-7.0)• ICU – 2300 – BE = (-5.8)• ICU – 0254 – BE = (-5.7)• Urine Output ICU – 50cc/hr• Hb – 10.0 (0400)

PID # 1 PID # 1

OR for Femur Fracture – 0800 PID # 1

• 0900 – 1 liter LR• 0925 – 60/20• 0945 – 70/25 1 liter LR• 0950 – 70/25 Phenylephrine 100 mcg• 0955 – 70/20 Phenylephrine 100 mcg• 1000 – 75/45• 1005 – 90/40• 1025 – 100/40• Total IVFs – 4300 ml• EBL – 150cc• Urine – 230 ml

PID # 1 - Anesthesia Record

Hospital Course

• Rehab – PID # 10

Base Deficits

• 0515 - 10.4• 0815 - 7.4• 1004 - 8.5• 1454 - 4.3• 2014 - 3.0• 2157 - 3.2• 2351 - 2.6• 0232 - 0.8

Conclusions

• The complexity of simultaneous resuscitation and obtaining surgical control of massive hemorrhage cannot be underestimated.

• Massive transfusion protocols • Calcium and Cryopreciptate • Ideal resuscitation as a moving target• Teamwork and Communication

References

• Cotran, R., Kumar, V., Collins,T. (1999). Robbins pathologic basis of disease (6th edition). Philadelphia, PA: W.B. Saunders Company.

• Donohoe Dennison, Robin (2000). PASS CCRN! (2nd edition). Missouri: Mosby, Inc

• Gaieski, D., Parsons, P., Wilson, K. Shock in adults: Types, presentation, and diagnostic approach. UpToDate 2008.

• Todd, J., Wesley (1997). The Cardiovascular Review Book for Invasive Cardiovascular Technology Vol I.: Anatomy, Physiology & Pathology.

Self Published by Cardiac Self Assessment• Todd J., Wesley (1997). The Cardiovascular Review Book for Invasive

Cardiovascular Technology Vol II.: Invasive Diagnostic Techniques. Self Published By Cardiac Self Assessment.

• White, K. (2003). Fast facts for adult critical care. Mobile, AL: Kathy White learning systems.

Death?

Total

Respond‐

ing

NC 17 17 100.0% 10.6%

NE 41 38 92.7% 23.8%

NW 20 19 95.0% 11.9%

SC 49 48 98.0% 30.0%

SE 20 19 95.0% 11.9%

SW 20 19 95.0% 11.9%

Total 167 160 95.8% 100.0%

Response Totals by EMS Type

Total %

37 22.8%

117 72.2%

8 4.9%

162 100.0%

Response Totals by EMS Staffing

Total %

54 32.9%

36 22.0%

74 45.1%

164 100.0%

44 27.7%

91 57.2%

23 14.5%

1 0.6%

159 100.0%

33 20.9%

84 53.2%

38 24.1%

3 1.9%

158 100.0%

*Five services were out of state, four of which responded. These

services are excluded from tables showing regional counts, but are

included in all other results.

Staff completing the PHTLS training programs

are better prepared to care for trauma

patients.

1. Strongly Agree

2. Agree

3. Neutral

4. Disagree

This service is better able to handle trauma

cases as a result of staff completion of PHTLS

training.

EMS Trauma Education Survey


Region

# of EMS Services*

Response

Rate

% of All

Respond‐

ing

c) Paid and Vol.

Total

Total

Total

1. Strongly Agree

2. Agree

3. Neutral

4. Disagree

a) Type I

Type of EMS Service

a) Paid only

b) Volunteer only

Staffing of EMS

Total

c) Type V

b) Type II

Respondent % by RegionNC, 10.6%

NE, 23.8%

NW, 11.9%

SC, 30.0%

SE, 11.9%

SW, 11.9%

Usefulness of Training

27.7%

0.6%

53.2%

24.1%

1.9%

57.2%

14.5%

20.9%

0.0% 25.0% 50.0% 75.0% 100.0%

1. Strongly

Agree

2. Agree

3. Neutral

4. Disagree

Staff Better Prepared with PHTLS Service Better Prepared with PHTLS

Response Rates by Region

100.0%

92.7%

95.0%

98.0%

95.0%

95.0%

0.0%

25.0%

50.0%

75.0%

100.0%

NC NE NW SC SE SW

Respondent % by EMS

Type a)

Type

I,

22.8%

b)

Type

II,

72.2%

c)

Type

V,

4.9%

Respondent % by

Staffinga)

Paid

only,

32.9%

b)

Volun

teer

only,

22.0%

c)

Paid

and

Vol.,

45.1%

Page 1 of 2

EMS Trauma Education Survey

Attendants, including all First Responders, EMTs, and Paramedics, full and PT, providing care in your service.

Region

NC

NE

NW

SC

SE

SW

Total

371 179

1300 516 784 60.3%

4560 1533 3027 66.4%

294 61.5%

398 90 308 77.4%

192 51.8%

478 184

1638 492 1146 70.0%

375 72 303 80.8%

Total Number # With PHTLS Training # Needing Training

% Needing

Training

# Needing PHTLS Training

1146

303 308

784

192294

0

200

400

600

800

1000

1200

1400

NC NE NW SC SE SW

% Needing PHTLS Training

80.8% 77.4%

60.3%70.0%

51.8% 61.5%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

NC NE NW SC SE SW

Barriers to Attendance (N=164)

38.4%

19.5%

57.3%

1.2%

20.1%

7.3%

36.6%47.6%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Facility Space Cost of

Hosting

Lack of

Instructors

Staffing

Coverage

Staff Interest Cost of

Sending Staff

Getting Time

Off

Other

Page 2 of 2

Total*

Respond‐

ing

NC 13 13 100.0% 10.2%

NE 33 33 100.0% 26.0%

NW 18 18 100.0% 14.2%

SC 31 31 100.0% 24.4%

SE 14 14 100.0% 11.0%

SW 18 18 100.0% 14.2%

Total 127 127 100.0% 100.0%

Total %

Com‐

bined %

43 34.7%

44 35.5%

14 11.3%

23 18.5%

124 100.0% 100.0%

90 72.0%

35 28.0%

125 100.0%

24 40.7%

23 39.0%

12 20.3%

59 100.0%

Hospital Trauma Education Survey

Staff completing the ATLS and/or TNCC are

better prepared to care for trauma patients.

Region

Response

Rate

Hospital licensed

beds

a) 0‐24 beds

b) 25‐49 beds

*Represents all Critical Access Hospitals, and acute care facilities providing

trauma services.

70.2%

29.8%

This hospital is better able to handle trauma

cases as a result of participating in RTTDC

training.*

Total

% of All

Respond‐

ing


a) Strongly Agree

*65 hospitals indicated that they had not yet completed RTTDC training, so they were excluded from the response calculations for this question.

# of Hospitals

a) Strongly Agree

b) Agree

Response Totals by Licensed Bed Count

c) 50‐100 beds

d) >100 beds

Total

b) Agree

c) Neutral

Total

Hospital licensed bedsa) 0‐24

beds,

34.7%

b) 25‐49

beds,

35.5%

c) 50‐100

beds,

11.3%

d) >100

beds,

18.5%

Respondent % by RegionNC, 10.2%

NE, 26.0%

NW, 14.2%SC, 24.4%

SE, 11.0%

SW, 14.2%

Usefulness of Training

72.0%

28.0%

40.7%

39.0%

20.3%

0.0% 25.0% 50.0% 75.0% 100.0%

a) Strongly

Agree

b) Agree

c) Neutral

Staff Better Prepared with ATLS/TNCCHospital Better Prepared with RTTDC

Response Rates by Region

100.0%

100.0%

100.0%

100.0%

100.0%

100.0%

0.0%

25.0%

50.0%

75.0%

100.0%

NC NE NW SC SE SW

Role in the organization for person

completing the survey (N=127)Chief Executive

Officer

(CEO), 7.9%

Chief Nursing

Officer

(CNO), 37.8%

Emergency

Department

Director,

11.0%

Emergency

Department

Nurse

Manager,

17.3%

Emergency

Department

Staff Nurse,

0.8%

Other, 25.2%

Page 1 of 3


Physicians, PAs, and ARNPs, full and part‐time, providing coverage in ED as primary care provider

Region

NC

NE

NW

SC

SE

SW

Total

RNs and LPNs, full and part‐time, providing nursing care in ED

Region

NC

NE

NW

SC

SE

SW

Total

925

30

157

28

126

32

425

81

52

345

48

81

76

253

89

60.5%

127

37 41.6%

Total Number # With TNCC Training

54.1%

51

188

63.0%

# Needing Training % Needing Training

49

500

54.5%

63.2%

50.2%

938 641 297 31.7%

202 111 91 45.0%

238 155 83 34.9%

166 28.6%

201 136 65 32.3%

581 415

279 143 136 48.7%

Total Number # With ATLS Training # Needing Training % Needing Training

2439 1601 838 34.4%

# Needing ATLS Training

51

188

48 37 49

127

0

50

100

150

200

250

300

NC NE NW SC SE SW

% Needing ATLS Training

63.0%54.5%

63.2%

41.6%

60.5%50.2%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

NC NE NW SC SE SW

# Needing TNCC Training

91 83

166136

297

65

0

50

100

150

200

250

300

NC NE NW SC SE SW

% Needing TNCC Training

45.0%

31.7% 34.9%

28.6%

48.7%

32.3%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

NC NE NW SC SE SW

Page 2 of 3


Barriers to Attendance (N=127)

15.7%

38.6%

15.7%

69.3% 65.4%

11.0%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

Facility Space Cost Lack of

Instructors

Staffing

Coverage

Staff Interest Other

Page 3 of 3

Meeting Room 1-2nd Floor Topeka 1:00pm to 4:00pm April 26, … · 2010-07-01 · Northeast Regional...

Documents

Transcript of Meeting Room 1-2nd Floor Topeka 1:00pm to 4:00pm April 26, … · 2010-07-01 · Northeast Regional...