PERIOPERATIVE COMPLICATIONS OF TRAUMA

(Near) MissesCase Discussions

Linda E. Pelinka, M.D., Ph.D.Medical University of Viennaand Ludwig Boltzmann Institute

for Experimental & Clinical TraumatologyVienna, Austria, European Union

TRAUMA

THE PREHOSPITAL

SETTING Airway management

Scoop & Run or Stay & Play?

……while it is while it is

critically important to learn critically important to learn

the skills of intubation, the skills of intubation,

knowing the sequence knowing the sequence

and tasks alone and tasks alone

does not guarantee successdoes not guarantee success. .

IS THE TUBE IS THE TUBE WHERE IT SHOULD BE?WHERE IT SHOULD BE?

Visualization of ETT passing through cordsVisualization of ETT passing through cords

Auscultation of breath soundsAuscultation of breath sounds

Condensation inside the ETT Condensation inside the ETT

Symmetric chest rise/fall with ventilationSymmetric chest rise/fall with ventilation

Absence of sounds over epigastriumAbsence of sounds over epigastrium

Have all been shown to be Have all been shown to be unreliable unreliable

in the in the hospitalhospital setting setting

Swanson ER et al. Air Medical Journal 2005; 24/1: 40-6.Swanson ER et al. Air Medical Journal 2005; 24/1: 40-6.

Are likely to be even less reliable Are likely to be even less reliable

in the in the prehospitalprehospital setting setting

MONITORINGMONITORING

Pulse OximetryPulse OximetryCapnography Capnography

PULSE OXIMETRY – PULSE OXIMETRY – ININDIRECT techniqueDIRECT technique

is reliable for oxygenation, is reliable for oxygenation,

but measures oxygenation but measures oxygenation

inindirectly.directly.

Green SM, Krauss B, Academic Emerg Med 2002; 9: 35-42.Green SM, Krauss B, Academic Emerg Med 2002; 9: 35-42.

MONITORINGMONITORING

CAPNOGRAPHYCAPNOGRAPHY – – DIRECT technique DIRECT technique

detects detects

breathing abnormalities directly and breathing abnormalities directly and

almost immediatelyalmost immediately

apnea: loss of COapnea: loss of CO22 wave. wave.

AMERICAN POINT OF VIEW:

Patient unconscious and full stomach,

INTUBATION MANDATORY to avoid

danger of vomiting & aspiration, however:

RSI

MONITORING MANDATORY

EUROPEAN POINT OF VIEW:Patient unconscious, however:Breathing spontaneouslySufficient O2sat considering asthmaFull stomachHospital 15 min awayWHY INTUBATE? RISK OF INTUBATION vs. RISK OF ASPIRATION

Outcomes after out-of-hospital endotracheal intubation errors

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%)

,

Wang HE et al, Resuscitation 2009; 80/1: 50-55.

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.

Safety of orotracheal intubation in patients with unstable cervical spine fracture or high spinal cord injury.

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.

Shatney CH et al. Am J Surg 1995; 170: 676-80.

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.

Prehospital airway managementfor severe brain injury

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.

Parr M. Resuscitation 2008: 76, 321-322

Prehospital airway managementfor severe brain injury

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.

Parr M. Resuscitation 2008: 76, 321-322

PREHOSPITAL PREHOSPITAL INTUBATION INTUBATION

of SEVERE TBI? of SEVERE TBI?

trauma.org 2007

GOAL: MINIMIZE SECONDARY BRAIN DAMAGE

HYPOXIA

HYPOTENSION

Chesnut R, New Horizons 2000

SECONDARY BRAIN DAMAGE

DOUBLEDOUBLE

MORTALITYMORTALITY

AFTER AFTER

TBITBI

Trauma in the prehospital setting:

QUESTION #1

Is an airway necessary right away or can it wait until the hospital?

Trauma in the prehospital setting:

QUESTION #2

If an airway is necessary, is there any additional

(airway) difficulty?

Patients die of LACK of OXYGEN…

…not of LACK of an ETTconsider

supraglottic devices

Main problems

blood loss and shock

Scoop &run w/o intubation (Europe):

GET TO SURGERY ASAP

Hemo-pneumothorax:

NO INTUBATION

W/O CHEST DRAINRISK OF INTUBATION vs. RISK OF ASPIRATION

THE ER SETTINGemergency room priorities

ICP

CBV CPP

CBF

SECONDARY BRAIN DAMAGEVICIOUS CYCLE

AUTOREGULATIONAUTOREGULATION

Differential Diagnosis

Hypotension

Tachycardia

Tachypnea

Is it really what I think it is?

Assuming

is actually

Frequency Gambling

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

In minor head injury

CT may be negative

despite brain damage.

If CT is negative

consider MRI.

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.

Two things are infinite –the universe

and human stupidity…

Albert Einstein

...and I’m not sure about the universe.

THE OR SETTINGhemorrhagic shock

airway management

postoperative neuroimaging

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.

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

Findings:Decreased transfusions in penetrating trauma, but

not statistically significant Statistically significantly decreased

transfusions in blunt trauma.No safety issues, no thromboembolic events.

2 of 2

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.

ADRENERGIC AGENTS ICU vs OR

DRUG DOSE MIMETIC

NOREPINEPHRINE0.04-0.4

µg/kg/mindirect

90% Alpha

DOBUTAMINE 2-20 µg/kg/mindirect

90% Beta

EPINEPHRINE 100-200 µg/kgindirect

Alpha & Beta

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.

CHECKING CT

AFTER BRAIN SURGERY IS

STATE OF THE ART

TAKE HOME

MESSAGES

AMERICAN POINT OF VIEW:Patient unconscious and full stomach,

INTUBATION MANDATORY to avoid danger of vomiting &

aspiration, however :RSIMONITORING MANDATORY

EUROPEAN POINT OF VIEW:Patient unconscious, however:Full stomachHospital close bySufficient O2sat

Risk of intubation vs. Risk of aspiration

Hemorrhagic Shock

Get to surgery ASAP

Scoop & Run

over

Stay & Play

Is it really what I think it is?

Assuming

is actually

Frequency Gambling

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

In minor head injury

CT may be negative

despite brain damage.

If CT is negative

consider MRI.

CHECKING CT

AFTER BRAIN SURGERY IS

STATE OF THE ART