Resuscitation: Special Circumstances Part 2

ResuscitationOSCE
Written By Yusra Qamar

Part 2 of our resuscitation series looks at resuscitation in trauma and how our management approach differs in the ED, management and cardiac arrest setting.

In this week’s blog, we will cover the following:

  1. Key definitions

  2. Approaching the trauma patient

  3. Management principles

  4. Traumatic Cardiac arrest

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1.     Key definitions

Major trauma:

  • Injury or combination of injuries that are LIFE THREATENING and could be life changing because it may result in a long term disability i.e. loss of limb

  • Injury severity score >=15

 

Major trauma centre (MTC):

  • Multispecialty hospital with facility to manage all trauma patients. Consultant led 24/7, 365 days

 

Major trauma unit:

  • Facility to stabilise major trauma for transfer to MTC. i.e. unable to provide immediate specialist care for major traumas e.g. gunshot wounds

 

Damage control resuscitation: (DCR)

  • DCR is the principle haemostatic resuscitation – avoid excessive crystalloid and replace with guided blood products (blood, FFP, use ROTEM) External pressure

    • Haemostatic gauze

    • Tourniquets

    • Pelvic binder

  • Permissive hypotension

  • Avoid lethal triad

  • CRASH 2 trial: Early tranaxemic acid (TXA)

    • Loading dose: 1g over 10 min, followed by 1g over 8hr

    • TXA safely reduced the risk of death in bleeding trauma patients

  •  CRASH 3 trial:

    • Early TXA (within 3hr) did not result in a significant reduction in TBI associated death at 28 days, however it also does not appear to cause harm.

  • Damage control surgery (DCS)

Damage control surgery (DCS):

·      DCS is the management (3 phases)

·      Phase 0 – Initial resuscitation and restoration of physiology

o   Phase 1 – abbreviate laparotomy

o   Phase 2 – stabilization on ICU

o   Phase 3 – Further exploration

 

Major haemorrhage:

·      >1 circulating blood volume in 24h. (approx. 70ml/kg or approx. 5L in 70kg adult)

·      50% total blood volume loss in <3h

·      Bleeding >150ml/min adults

 

Massive transfusion:

·      Complete replacement of circulating volume in 24h

·      50% blood volume transfused in 4hr

·      10 units given in 24h

2.     Approaching the trauma patient.

Your first assessment of the trauma patient is likely to be in the Emergency Department.  

General principles:

ATLS approach, call for help

Primary survey – cABCDE + Ruling out/looking for immediate life threatening injuries: ATOM – FC

A – Airway obstruction

T – tension pneumothorax

O – open pneumothorax

M – massive haemothorax

F – flail chest

C – cardiac tamponade


Key points of difference in your cABCDE approach include:

cA: (c/spine + Airway)

  • MILS

  • Assess for severe facial trauma, blood

  • ?need for intubation – predict difficult airway!

  • Maintain C spine precautions until cleared via guidance (see below)

B:

  • 100% oxygen.

  • If intubation required - RSI – trauma, pain and opiates are all associated with delayed gastric emptying

  • Cardio stable induction to minimise pressor response. Choice depends on preference but generally opiate, ketamine, rocuronium.

  • Remember lung protective + neuro protective ventilation

C:

  • IV access, fluid warmer

  • Resuscitate - IVF + blood products

  • Bloods, ABG, lactate, BC, ROTEM/Haemacue/Transfusion triggers , rapid infuser

  • FAST SCAN

  • HAEMORRHAGE ? Major haemorrhage protocol AND…

    • External pressure

    • Haemostatic gauze

    • Tourniquets

    • Pelvic binder

  • CRASH2: TXA

  • Rapidly reverse anticoagulation in patient who have major trauma with haemorrhage

    • Warfarin - vitamin K, Prothrombin Complex Concentrate (PCC)

    • Dabigatran - idarucizumab (aka Praxbind)

    • Apixaban/Rivaroxaban - Andexanat alfa (aka Ondexxya)

  • Discuss with haematologist if < 16 years or if on any other agent other than warfarin

D:

  • Pupil assessment

  • GCS assessment/AVPU

  • Don’t forget glucose!

E:

  • Assess abdomen, pelvis, long bones

  • Altered pharmacokinetics likely. SENIOR discussion early

 

Use the following mnemonic for a quick history:

A – allergies

M – Medications

P – Past medical history

L – Last meal

E – Events leading up to the presentation

 

3.     Management principles:

·      Avoid lethal triad:

1.     Hypothermia

2.     Acidosis

3.     Coagulopathy – Keep fibrinogen >2

·      DCR and DCS (see above)

·      Aim for radiological imaging if sufficient time/patient is stable

o   See NICE guidance CG176 on CT head/C spine imaging indications

o   See NICE guidance CG39 on Major trauma: Assessment and initial managent with regards to whole body CT

·      C spine clearance

o   Assess risk according to Canadian C spine rules – high, low or no risk (caution – applying these rules to children can be difficult and the child’s developmental stage should be taken into account)  

o   C spine can be cleared clinically or radiologically as determined by risk stratification

 

4.     TRAUMATIC CARDIAC ARREST (TCA)

·      Common Causes: hypovolaemic shock, obstructive shock, neurogenic shock

·      Focus: immediate, simultaneous treatment - Chest compressions MUST NOT DELAY treatment of reversible causes.

·      HAEMORRHAGE ?

o   External pressure

o   Haemostatic gauze

o   Tourniquets

o   Pelvic binder

·      FAST scan

·      Consider LIFE SAVING interventions

o   Haemorrhage control incl pelvic binder

o   Optimise oxygenation/ventilation

o   Vascular access

o   Rapid warmed blood/blood product transfusion

o   Bilateral thoracostomies

o   Resus thoracotomy – especially in penetrating trauma

Take a look at the ERC algorithm for the management of Cardiac arrest 2015:

 
 
Yusra Qamar

Yusra is an Anaesthetics Registrar working in Sydney, Australia. Her interests include personal development, leadership and education.

https://www.mosceto.com/dr-yusra-qamar
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