WHAT IS THE POINT OF THIS TALK? › uploads › sites › 2 › 2017 › 02 › Trauma_… · what...
Transcript of WHAT IS THE POINT OF THIS TALK? › uploads › sites › 2 › 2017 › 02 › Trauma_… · what...
WHAT IS THE POINT OF THIS TALK?
•1 HOUR OF CPD
•TAKE THE TRAUMA OUT OF TRAUMA
•IMPROVE OUR UNDERSTANDING OF TRAUMA SO WE CAN
PROVIDE BETTER CARE
WHAT IS TRAUMA?
TRAUMA = TISSUE INJURY
• Blunt trauma- RTA, kick, hit with
object
• Penetrating trauma- gunshot
wounds, stab wounds, bite wounds
• Environmental trauma- burns,
electrocution, frostbite
WHAT DO WE KNOW?
•TRAUMA >10% OF VET HOSP ADMISSIONS
•INVOLVES SERIOUS INJURIES IN APPROX. 35% OF CASES
•MORTALITY RATES APPROX. 10% IN DOGS
Ref: JVECC (2014) 24:1 pp 93-104
TRAUMA IMPACTS MANY LIVES!
WHAT ELSE DO WE KNOW?•UPTO 43% IN DOGS WITH BLUNT TRAUMA HAVE HAEMOABDOMEN
•INTRODUCTION OF FAST HAS INCREASED THE DETECTION OF POSTTRAUMA
HAEMORRHAGE
•DECREASED PLT COUNT PREDICTS BODY CAVITY HAEMORRHAGE
Ref: JVECC (2014) 24:1 pp 93-104
TRAUMA PATIENTS OFTEN BLEED INTERNALLY
WHAT DO WE KNOW?- MORE STATISTICS
• INCREASED LACTATE AND DECREASED BASE EXCESS PREDICT INCREASED MORTALITY
• aPTT WAS STRONGEST PREDICTOR OF DEATH IN ONE STUDY (SENS 67% SPEC 80%)
• STUDY RECENTLY- 13% RECEIVED GLUCOCORTICOIDS, 23% RECEIVED NSAIDS AND 3%
RECEIVED BOTH!!!!
Ref: JVECC (2014) 24:1 pp 93-104
BLOOD TESTS ARE GOOD! STEROIDS ARE BAD!!
HOW DO WE KNOW IT?
• HUMAN STUDIES
• RELEVANT TO ANIMAL POPULATIONS?
• DIFFERENCES- PARAMEDICS, BLOOD AND CT SCANNING, INJURY PATTERNS?
• OTHER HUMAN POPULATIONS- CHILDREN IN DEVELOPING COUNTRIES
• HUMANS USE ANIMAL MODELS- TRANSLATIONAL MEDICINE.
• VETCOT= VETERINARY COMMITTEE ON TRAUMA
EVIDENCE BASED MEDICINE
WHAT IS HAPPENING NOW?
• 26 ACTIVE VETERINARY TRAUMA CENTERS PARTICIPATING IN THE VETERINARY TRAUMA NETWORK
• A TOTAL OF 8,497 CASES HAVE BEEN ENTERED INTO THE TRAUMA REGISTRY TO DATE.
• VETCOT RESEARCH ON
• VALIDATING INJURY SCORES,
• PREDICTING TRANSFUSION REQUIREMENTS FOLLOWING TRAUMA
• PREVENTING HYPERFIBRINOLYSIS IN TRAUMA
MORE EVIDENCE BASED MEDICINE-COMING SOON…
HOW CAN WE IMPROVE TRAUMA CARE?
• 1. TRAUMA PATIENT CARE
• IMPROVED SURVIVAL,
• REDUCTION OF COMORBIDITIES
• DEVELOPMENT OF PROTOCOLS TO IMPROVE EFFICIENCY AND OUTCOMES.
• 2. RESEARCH COLLABORATIONS
• DEVELOPMENT OF EVIDENCE-BASED MEDICINE PROTOCOLS
• EVALUATION OF MINIMALLY INVASIVE, COST-EFFECTIVE INTERVENTIONS
• TRANSLATIONAL MEDICAL OPPORTUNITIES)
• 3. EDUCATION ON VETERINARY TRAUMA
VetCOT The Veterinary Trauma Initiative
TODAY’S FOCUS…
• BLUNT TRAUMA
• PATHOPHYSIOLOGY OF TRAUMA
• APPROACH TO TRAUMA CASES
• STABILISATION, MONITORING & INVESTIGATIONS
• NOT ORTHOPAEDICS!
• WHAT IS STRESSFUL ABOUT TRAUMA?
TAKING THE TRAUMA OUT OF TRAUMA
UNPREDICTABLE
DON’T say the
‘Q’ WORD!It is a well known fact that trauma cases are
most likely to occur
1) On a Friday afternoon
2) During breaks or attempted mealtimes
3) If anyone says it’s quiet
4) When you are short staffed and fully booked
TRAUMA TRAINING
• MANY OF US DIDN’T GET THIS
• RECENT ADVANCES IN TRAUMA CARE
• FEELING ‘OUT OF OUR DEPTH’
How
Can
Titanic
Help us
Save
Lives?
FEELING OUT OF OUR DEPTH?
BE PREPARED…
PLAN & PRACTICE, PRACTICE, PRACTICE…
TELEPHONE TRIAGE• TRAINING
• BRIEF DETAILS
• Contact Telephone Number
• ETA
• Animal’s Name/Surname
• Species (Breed also for dogs)
• FIRST AID INSTRUCTIONS (restraint, lifting,
bleeding)
• COMMUNICATION WITH CLINICAL STAFF
PRE-ARRIVAL
• ORGANISE TEAM
• WHO DEALS WITH THE TRAUMA PATIENT
• WHO DEALS WITH THE OWNER
• WHO WILL DEAL WITH EVERYTHING ELSE…
• WATCH OUT FOR THE ARRIVAL
• GET STUFF OUT- O2 TENT/CHECK FULL OXYGEN/ IV CATHETERS/MONITORING EQUIPMENT
LOOK OUT FOR WHAT’S COMING…
OWNER-ECTOMY
‘I’LL NEVER
LET GO…’(TITANIC MOVIE, 1997)
TRIAGE – PRIMARY SURVEY
•MAJOR BODY SYSTEMS
• CNS- MENTATION, PUPILS, POSTURE
• RESP- AIRWAY, RATE, PATTERN, SOUNDS
• CARDIOVASCULAR-MM, CRT, HEART
RATE/RHYTHM/SOUNDS, PULSES & TEMP
• RECORD IT!
TRIAGE – STABILISATION-A,B,C…
• A=AIRWAY #ET TUBE (ADVANCED AIRWAY
TECHNIQUES)
• B=BREATHING #OXYGEN #AMBU-BAG (CHEST
TAP)
• C=CIRCULATION #IV ACCESS (INTRAOSSEOUS,
JUGULAR)
• D=DRUGS=PAIN RELIEF
CLIENT CARE
• OWNER
• INFORMED CONSENT
• UPDATES
• THE CONCEPT OF ‘SHOCK’
• OTHER CLIENTS
• KEEP INFORMED OF WAIT
• OFFER TO RESCHEDULE NON-URGENT CASES
BE ‘KING OF THE WORLD’
WHAT LIES BENEATH?
TIME OF DEATH…
• 3 CRITICAL PERIODS WHEN PATIENTS DIE…
• IMMEDIATE- MINUTES
• INJURY TO BRAINSTEM, AORTA, HEART
• EARLY- HOURS
• HAEMORRHAGE, CNS INJURY
• LATE- DAYS
• COMPLICATIONS-INFECTION, MODS
}WE CAN SAVE THESE GUYS
PATHOPHYSIOLOGY OF TRAUMA
2 HIT
HYPOTHESIS…
2 IMPACTS = FIRST HIT
FIRST HIT
• FORCES APPLIED TO TISSUES
• STRETCHING
• COMPRESSION
• SHEARING
• MORE DAMAGE:
• MORE FORCE/ENERGY
• LESS ELASTICITY OF TISSUE
• LESS SURFACE AREA AVAILABLE TO ABSORB THE FORCE
NEWTON’S 2ND LAW
FORCE = MASS x ACCELERATION
HOLLOW ORGANS
• BLADDER, DIAPHRAGM, BOWELS, ALVEOLI
• COMPRESSION CAUSES INCREASED INTRALUMINAL PRESSURE
• POP!
SOLID ORGANS
• SPLEEN, LIVER, KIDNEYS
• INTRACAPSULAR HAEMORRHAGE
• RUPTURED CAPSULE & HAEMORRHAGE
• SHEARING OFF OF VESSEL ATTACHMENTS- RAPID ACCELERATION-DECELERATION,
HEAD TRAUMA
Coup Contre-coup
LOOKING MORE CLOSELY: 2ND HIT
PARIS
WHAT LIES BENEATH?
SHOCK• DEFINITION: ‘INADEQUATE CELLULAR ENERGY PRODUCTION’
USUALLY DUE TO POOR TISSUE PERFUSION
Compensated Shock
• Mild-moderate mental depression
• Normal-prolonged CRT
• Tachycardia (or bradycardia in cats)
• Tachypnoea
• Normal pulses
• Normal blood pressure
Decompensated Shock
• Depressed/Collapsed
• Prolonged CRT
• Pale mucous membranes
• Weak peripheral pulses
• Decreased blood pressure
TRAUMA DEATH TRIADcoagulopathy
Metabolic acidosisHypothermia
• VICIOUS CYCLE DUE TO SEVERE
HAEMORRHAGE
HYPOTHERMIA
• HYPOTHERMIA BELOW 34° DECREASES COAGULATION PROTEASE FUNCTIONAL ACTIVITY AND PLATELET
AGGREGATION
• HYPOTHERMIA IS DUE TO POOR PERFUSION AND EXACERBATED BY ADMINISTRATION OF COOL IV FLUIDS
• MOST LAB TESTS ARE RUN AT NORMAL BODY TEMPERATURE
• MONITORING TEMPERATURE IS ESSENTIAL IN TRAUMA CASES
ACIDOSIS
• ACTIVITY OF CLOTTING FACTORS REDUCED BY AS MUCH AS 50% AT PH 7.2
• METABOLIC ACIDOSIS IS CAUSED BY LACTIC ACID PRODUCTION PRODUCED BY
POORLY PERFUSED TISSUES
• LAB MACHINES TEST AT NORMAL BODY pH
• CAGESIDE LACTATE MACHINES USEFUL FOR MONITORING SHOCK AND EFFECTIVENESS
OF INTERVENTIONS
COAGULOPATHYAcute Trauma Coagulopathy (ATC)
= systemic state of hypocoagulation and
hyperfibrinolysis.
Theoretical causes:
• severe tissue injury
• shock-induced hypoperfusion
• systemic inflammation
• endothelial damage
MY TRAUMA PATIENT IS STILL BLEEDING BECAUSE…• A. IT HAS BLED OUT LOTS OF CLOTTING FACTORS AND PLATELETS
• B. IT HAS ALSO USED THEM UP TRYING NOT TO BLEED FROM ALL THE DAMAGED TISSUES
• C. IT HAS THAT WEIRD CLOTTING DISORDER FROM TRAUMA (ATC) WHICH GOES AROUND DISSOLVING
ALL THE CLOTS IT HAS ACTUALLY MANAGED TO MAKE AS WELL AS NOT WANTING TO CLOT
• D. CRYSTALLOID FLUIDS AND DILUTED THE REMAINING CLOTTING FACTORS
• E. IT IS TOO COLD
• F. IT’S BLOOD IS TOO ACIDIC
• G. ALL OF THE ABOVE!!!
HOW DO WE KNOW WHAT LIES BENEATH?
WHAT ARE WE LOOKING FOR?
•CONTINUED BLEEDING
•THORACIC INJURIES
•SEVERITY OF SHOCK
TRILOGY OF TRAUMA TESTING
•BLOOD TESTING
•FAST ULTRASOUND TECHNIQUES
•MONITORING
BLOOD TESTS
•LACTATE
•MINIMUM DATABASE (PCV, TS, GLU& BUN)
•ACID-BASE
•COAGS (PT & APTT)
•SMEAR (PLTS)
MONITORING
•SPO2
•BLOOD PRESSURE
•ECG
•MOD GCS
•PAIN SCORE
FAST SCANNINGNothing to do with the supermarket
FAST = Focussed Assessment with
Sonography for Trauma/Triage
Rapid technique for assessing trauma
patients
aFAST= abdominal FAST
tFAST=thoracic FAST
Also VetBlue (Veterinary Bedside Lung
Ultrasound Exam) an extension to tFAST
AFASTPOSITION- Right lateral Recumbancy
4 VIEWS:
DH- just caudal to sternum
SR- left flank just caudal to last rib
HR- right flank just caudal to last rib
CC- just cranial to pelvis
Highly Sensitive and Specific for
Free Abdominal Fluid
AFASTSpot the black triangles…
TFASTTip!- use sternal recumbency in
respiratory compromised patients
and a roll of towel or paper towel
under forelimbs for better probe
contact
TFAST
• TRAUMA WET LUNG =
PULMONARY CONTUSIONS
(UNLESS PROVEN
OTHERWISE)
TFAST
Glide Sign
Helps rule out
pneumothorax
TREATMENT
PRIMARY AIMS:
• PREVENT SUFFERING
• RESTORE & MAINTAIN PERFUSION TO VITAL ORGANS
• ENSURE ADEQUATE OXYGEN CARRYING CAPACITY OF BLOOD
SECONDARY AIMS
• DEFINITIVE TREATMENT OF INJURIES TO RESTORE FUNCTION
• PREVENT COMPLICATIONS
PREVENT SUFFERING- ANALGESIAPure µ- opioids-
• Methadone
• Morphine
• Fentanyl
Reversible with Naloxone
Consider Regional Analgesia- line blocks
No to Steroids and NSAIDS
PREVENT SUFFERING
•IMMOBILISE FRACTURES AND COVER WOUNDS
•CONSIDER BENZODIAZEPINES TO IMMOBILISE FRACTURES AND HEAD
TRAUMAS
•COMFORT/WARMTH/SLEEP/WATER/NUTRITION
OXYGEN SUPPORT
O2 tent for cats Nasal Prongs for dogs > nasal oxygen catheter if need to stay on oxygen
FLUID THERAPY
AIMS
• IMPROVE BLOOD PRESSURE TO PREVENT ORGAN DAMAGE (MAP>60mmHg)
• BUT NOT TOO HIGH OR RE-BLEEDING WILL OCCUR (MAP<70mmHg)
• FIELD PARAMETER OF IMPROVED MENTAL STATUS AND DORSAL PEDAL PULSE IN ANIMALS
• MAINTAINING PERFUSION HELPS PREVENT THE DEATH TRIAD
• CRYSTALLOID BOLUSES- LACTATED RINGERS SOLUTION
MONITOR BLOOD PRESSURE AND BLOOD LACTATE + PULSE QUALITY & MUCOUS MEMBRANES
FLUID THERAPY• TISSUE OXYGENATION REQUIRES BLOOD OXYGEN CARRYING CAPACITY
• PACKED RED BLOOD CELLS
• WHOLE BLOOD
• (OXYGLOBIN)
• HYPOCOAGULATION REQUIRES CLOTTING FACTORS
• FRESH FROZEN PLASMA
• WHOLE BLOOD
HEAD TRAUMA CONSIDERATIONS• PERFUSION OF BRAIN = MEAN ARTERIAL PRESSURE (MAP) – INTRACRANIAL PRESSURE
(ICP)
• TREAT HYPOTENSION FIRST
Increased ICP
SYSTEMIC BLOOD PRESSURE MUST BE HIGH ENOUGH TO PERFUSE BRAIN TISSUE SAP>90
Pushing blood into brain->
DAMAGE CONTROL CONCEPT• HYPOTENSIVE RESUS TO ALLOW ADEQUATE PERFUSION WITHOUT DISRUPTING
THROMBUS FORMATION.
• FRESH WARM BLOOD>BLOOD PRODUCT COMBO (PRBC, PLASMA,
PLATELETS)>CRYSTALLOIDS
• THE CHALLENGE IS NON-COMPRESSABLE HAEMORRHAGE
• NEED EARLY IDENTIFICATION
• NOT EVERYWHERE HAS LOTS OF BLOOD PRODUCTS AND PERSONNEL
• IF CANNOT STABILISE OR RELAPSE INTO SHOCK NEED SURGERY IMMEDIATELY
Following major haemorrhage…
HAEMOSTATIC RESUSCITATION• SEVERE HAEMORRHAGE REQUIRES HAEMOSTATIC RESUSCITATION
• BLOOD PRODUCTS INCLUDING
• SHED BLOOD (AUTOLOGOUS BLOOD TRANSFUSION)
• WHOLE BLOOD
• BLOOD COMPONENT THERAPY - RECOMMENDED 1:2 FFP:PRC
• WARMING
• IDENTIFY SOURCE & SECONDARY SITES, APPLY DIRECT PRESSURE/ABDOMINAL WRAP
ABDOMINAL WRAP• Include the hindlimbs!
• Use upto 48 hours with pressure of
20-25mmhg (to avoid abdominal
compartment syndrome)
• Survival rates increase using this in
haemoperitoneum.
• Contraindicated if diaphragmatic
hernia is present-pushes organs
into chest
AUTOLOGOUS BLOOD TRANSFUSION
Empty fluid bag with attached
giving set
20ml syringe
Large bore needle
AUTOLOGOUS BLOOD TRANSFUSION
POTENTIAL COMPLICATIONS/PRECAUTIONS
• INFECTION- ALTHOUGH ONE STUDY SHOWED EXCELLENT SURVIVAL EVEN WITH CONCURRENT BOWEL
PERFORATIONS
• NEOPLASTIC METASTASIS
• USE AN INLINE FILTER OR BLOOD ADMINISTRATION GIVING SET
• FOLLOW UP WITH FFP
AUTOLOGOUS BLOOD TRANSFUSION• TAKING SHED BLOOD FROM THE ABDOMEN OR THORAX AND TRANSFUSING IT
• In <1 hour the blood will have undergone
fibrinolysis- no anticoagulant required!
• Readily available source of pre-warmed type-
specific blood
• Collection is easy!
• Can give as fast as you want (don’t use a fluid
pump)
DAMAGE CONTROL SURGERY
• NOT definitive repair
• Aim is to control haemorrhage
• ‘Get in, Get out’
• Pack Abdomen, temporary closure
• ICU then second surgery
State of the art…
IMPORTANT POINTS
•BE PREPARED
•CHECK WHAT IS GOING ON BENEATH THE SURFACE
•PRACTICE FAST SCANNING
I want to be able to honestly tell the owner (and myself), ‘I did everything I could’
QUESTIONS????
Thanks for listening!