Hello, my name is Jose Diaz. I am a trauma acute care surgeon at the University of Maryland R. A. Cowling Shock Trauma Center. My task for you this morning is to present and go over the monitoring and stabilization of the trauma patient. The multi-professional critical care course review is primarily for adult patients and I will focus on adult trauma patients. I have no disclosures. My only disclosure is that my opinions are my own. It should not in any way be reflective of the American College Surgeons Committee on Trauma or the ATLS program. Trauma can be both a result of blunt trauma or penetrating trauma. We've recognized in the last several years here recently that penetrating trauma has been increasing in the United States. Most patients usually end up at a level one trauma center where there are large teams that take care of these patients. There are level two trauma centers as well as level three and four trauma centers in the country where trauma patients are admitted to the ICU and a non-trauma intensivist would have to take care of these patients. So familiarizing yourself with these patients is very key and important. The outline for today's talk is utilize appropriate organizational and team management strategies to conduct a primary, secondary, and tertiary survey of the injured patient. Identify high-risk mechanisms for injury and their associated injuries. Apply principles of hemostasis and stabilization of fractures early in the care of the injured patient. So what's new? Although there is not a whole lot new, I'm going to try to bring you at least what's new over the last five years or so. EFAS, the use of less crystalloids, more blood products. What is damage control resuscitation, TEGS or Rotem, and the use of TXA in trauma. So we are now up to the 10th edition of the ATLS book or the Advanced Trauma Life Support book. The chapters are as you see on the slide. If you go and take an actual ATLS course, you will go over the initial assessment of the trauma patient, management of airway and ventilation, shock, thoracic trauma, abdominal pelvic trauma, head injury, spine, spinal cord injury, musculoskeletal trauma, thermal injuries, pediatric trauma, geriatric trauma, trauma and pregnancy and intimate partner violence, and then definitions for transfer to higher level of care. So management of the patient in a trauma bay is a coordinated chaos. So usually the management of the patient as they arrived, designated areas for specific individuals to be. But the focus there is primarily the initial assessment of the patient, identifying someone who is at high risk of mortality, requiring active resuscitation, active diagnosis prior to going for further treatment, and or further assessment via imaging processes. So your patient arrives to the emergency department. Your initial job as you are in the emergency department, if you are called down to assist, is assess the airway. In any situation, you need to control the cervical spine for fear that there may have been a cervical injury, especially in blunt trauma. You need to assess whether or not the patient is having any difficulty breathing and as such needing assistance with ventilation. You need to assess whether or not the patient is hypotensive, whether or not there is evidence of active hemorrhage and the need for hemorrhage control. You need to assess whether or not the patient is manifesting disabilities, either due to injury to an extremity or to the spinal cord or even traumatic injury after a head injury. You need to demonstrate all this by exposing the patient, removing all clothing and dressing so you can see whether or not there is an injury somewhere, but at the same time making sure that the patient is limited exposure to the environment as these patients can lose temperature quickly. So during your primary survey, your goal is to identify whether or not the patient is having any difficulty breathing or does not have an airway. Usually it's going to require that you institute an oral endotracheal intubation. Many times the patient is transferred in either being bagged masked or some other attempt at trying to get an intubation in a patient who has lost consciousness or who has altered mental status. Occasionally, there is such damage within the midface that a surgical airway needs to be obtained. Determining whether or not the patient had difficulty breathing as a result of a pneumothorax or tension, pneumothorax or hemothorax must be assessed. Although there is good data to demonstrate that a small caliber tube can be used to re-expand the lung, my recommendation is that you place a chest tube in a patient who needs emergent placement of a tube to decompress the tension pneumothorax. Patients also require IV access for their resuscitation. All patients should undergo placement of an extremity IV greater than 18 gauge as this allows for large volume resuscitation if necessary. In patients presenting with extremity injury and exsanguination, the use of tourniquets has been demonstrated to be lifesaving. Going back to the military conflicts of the last previous decade, tourniquet use as a result of IEDs resulted in significant success in survival. This has been demonstrated also in civilian trauma. EFAS to quickly assess whether or not the patient has evidence of intracavitary bleeding is important. The field placement of the emergency tourniquet, which most EMS crews now carry, again, as I mentioned, is important. It is important to demonstrate how to put these on. In most ATLS courses, the participants are taught to place these. These can actually be purchased easily online. So in this table, we will go over the various different classes of hemorrhagic shock as defined by the amount of blood volume as well as hemodynamic parameters the patient may present with. So class one is typically defined as the equivalent of giving a unit of blood. Blood loss is usually less than 50% of the total blood volume. Certain patients may or may not manifest any change in heart rate. There should not be a change in the blood pressure. There may or may not be any changes in pulse pressure as well. Class two shock is mild shock. The patient may or may not have lost anywhere between 15 to 30% of their blood volume. At this point, you may see slight changes in their heart rate as well as blood pressure, but you will definitely see changes in their pulse pressure if you're astute enough to monitor that. Your patient presenting in shock or hypotension is in class three shock. These patients have lost anywhere between 30 to 40% of their blood volume. They are tachycardic into the 120s and higher. They are hypotensive, usually in blood pressures in the 90s or less, and definitely drop in their pulse pressure. These patients should be resuscitated and determined to see whether or not they respond to resuscitation. If they do not respond to resuscitation, then they're probably in class four shock. These patients have lost more than 40% of their blood volume. They're usually very tachycardic in the 150s to 160s. They're in profound hypotension and manifesting alterations in their pulse pressure. These patients, if not resuscitated and hemorrhage stopped, will die usually within half an hour or less. This is the follow-up to the hemorrhagic for the various different classes. If you were able to follow respiratory rate and you're an output, you would see a drop going across from class one to class four shock. It's important to recognize that your patient presenting with altered mental status may actually be in shock, as opposed to just having had, also could be hypoxia, as opposed to some other drug action. As you've heard, and I would imagine at this point, the use of a resuscitative balloon has been the rave here in the last many years and the use of trauma of non-compressible shock. Tourniquets, as I mentioned earlier, can be used on the extremities, but as far as in truncal injury, whether it's abdominal or chest, may or may not be able to be directly compressed. On the top of the slide is the ER roboa catheter, which is now the primary catheter used in the most emergency departments. As you can see, this catheter can be placed via femoral access. The bottom left cartoon demonstrates an aorta with an inflated balloon. It is usually placed via percutaneous access into the femoral artery near the inguinal ligament. A introducer is usually used. It can be placed with a 7.5 French introducer. Two positions are usually selected. On the right of the screen, you see the aortic zone 1, aortic zone 2, and aortic zone 3. These correspond to where the balloon would be placed. Aortic zone 1, where the balloon would be placed above the diaphragm for a potential injury to the intra-abdominal cavity. We do not inflate the balloon in zone 2, which is the area where the mesenteric as well as the renal arteries are. Zone 3 is an area where we'll inflate the balloon in the event that we are concerned that there are pelvic injuries. There's quite a bit of data now as far as the use of the roboa balloon to assist on and help patients survive. This is one of the early papers dating back to 2015. In this paper, it compared the patients who underwent placement of roboa versus ED thoracotomy. There were 72 patients that underwent resuscitative thoracotomy and 62% died in the emergency department. There were 24 patients that underwent placement of roboa, of which 16 died in the emergency department. The location of death was significant between the roboa versus resuscitative thoracotomy. The roboa had fewer deaths and improved overall survival compared to resuscitative thoracotomy. The other thing that I think is important to recognize is that patients had to die to get a resuscitative thoracotomy. It is important to recognize today that we know that a roboa should be placed prior to the patient arresting, and it's definitely easier to place the femoral catheter introducer before the patient actually had arrested. The BEST course is designed to educate those to place the catheter and assess timing for placement of the roboa in a timely fashion. When patients are presenting with hypotension, it makes you sure that there's femoral access. Usually a chest x-ray or some additional imaging is performed. You definitely want to make sure that their likelihood of an aortic injury is small, so you can go ahead and place a roboa. If the risk of having an aortic injury is high, then the recommendation currently is that you should not. So in the scenario of trauma, patients presenting with hemorrhage can result in a lethal triad. They may present with significant acidosis with hypothermia, as well as progress to coagulopathy. We used to give quite a bit of fluid in this patient population, which ended up resulting in worsening of the acidosis. And over the last many years, and with the experience of the military conflicts, we've recognized that blood resuscitation is superior to just using a crystalloid. So in patients who present with shock, you should start blood products early, especially if you have clinical evidence of class 3 or class 4 shock. The risk of transfusion defined as 10 units of blood in greater than 24 hours or 4 units within one hour. You should use Teg or Rotem, whichever your institution has decided to utilize, can be used to help guide your resuscitation. In a pre-hospital setting, a TXA may be appropriate, especially in severe settings. It's important to recognize that you should go through a quick series of possibilities of where your patient is bleeding. Your patient is either bleeding into the street, there could be bleeding into their chest, into their abdomen, into the retroperitoneum, or into their thighs if they were to have femoral injuries. It's a clinical flow diagram used by the military to assess potential injury. So in patients with symptoms of shock and a potential risk of an extremity injury, you have to think about whether or not there's a cavitary bleeding, whether it's thoracic, abdominal, or even at the groin at the junctional areas. Initial resuscitation is started, you have to get appropriate IV access as mentioned. In the appropriate patient, you should think about whether or not you should get a TXA. Appropriate laboratory as well as hemodynamic parameters should be collected. And you should continue to resuscitate the patient until there's somebody there that can help stop the bleeding. So 10 rules of trauma resuscitation. The goal is to prevent death from hemorrhage and recognizing that this is a team sport and resuscitation is the name of the game. If you anticipate the need for more than three to four units of packed cells in the first few hours, you're in it for sure. One in four trial patients is bleeding abnormally from the get-go and here's why. Limit the amount of fluid crystalloid that you're giving the patient that does not benefit. Like normal saline, does not clot and does not carry oxygen. Give blood products, red cells, plasma, and platelets in a balanced format that we're going to review here in a minute. Use massive transfusion protocols or your institution should have developed massive transfusion protocols to help blood component therapy. In the appropriate setting and in an appropriately selected patient, TXA is a benefit. Perprinogenol less than 1.0 is indication for cryoprecipitate. If you resuscitate based on vital signs alone, odds are is that you're going to under resuscitate about 50% of the patients. Use base deficit, monitor lactate, monitor your urine output to continue monitoring your resuscitation. Here's our first question. Restrained patient transferred to the emergency department after a T-bone motor vehicle crash with a heart rate of 110, systolic blood pressure of 90, a respiratory rate of 35. Is complaining of left shoulder pain, shortness of breath, and left chest pain, left hip pain. What is the most concerning sign? Let me go back for a second. Most concerning is respiratory rate. Trauma resuscitation. Secondary survey. Secondary survey. Secondary survey is a complete evaluation after the primary survey from head to toe. Eyes and fingers in every orifice. You want to make sure that you're not missing anything. And part of this is making sure that you collect an ample history. So you want to calculate a Glasgow scale used to monitor altered mental status and get an assessment of disability. You want to be able to go through the top to bottom head and neck exam, chest exam, abdomen exam, and limb extremities. Utilize the EFAS or ultrasound point of care assessment for trauma. Looking at the subopatic space in the area near the right kidney, making sure that there's no fluid in Morse's pouch that could suggest bleeding. Similar format, you're looking at the kidney and the spleen in the left upper quadrant. You're going to look at the heart and the subcostal area and external views to make sure that there is no fluid around the pericardium. You're going to look into the abdomen, making sure there's no free fluid into the pelvis. The EFAS component today is also looking at the chest, both the left and right, to make sure that there is lung sliding, to make sure that there is no evidence of a pneumothorax. All of this can be done in a very quick time. On the slide, you see in the right upper quadrant, free fluid in the space of Morrison. On the left, you can see the spleen and how it appears next to the kidney. On the bottom two slides on the left, you see the view of fluid next to the bladder. And down on the bottom right, you see the view with blood in the pericardium. So a little flow diagram as far as utilizing the EFAS is concerned. In patients who are hemodynamically stable, you should proceed to perform an EFAS. If you have findings, then these patients could go to laparotomy, making the decision for surgery very quickly. If they are negative, then you can proceed for further evaluation. In the stable patient, you perform the EFAS and look for potential findings. Both of these today usually end up in the CT scanner to do further imaging, either to identify or to further delineate a potential injury. This is a reminder of the ample information that you need to collect, and it is important that many times the patients may become either unable to provide any additional history because they are now intubated, or during the continued course, they may develop or need additional pain medication requirements, resulting in them not being able to give a clear history. So the ample history is allergies, medications, past medical history, last meal, and events or environment related to the time of injury. You should get plain films, and it's still important, and it's still part of the ATLS, and we still get these in the emergency department. The chest x-ray gives us a lot of information, not only whether or not there is a hemo-pneumothorax, but also rib fractures, in addition to the potential for aortic injury. The pelvis film is important and utilized still to determine as far as whether or not there's any potential bleeding in the retroperitoneum or pelvis in a patient who presents unstable after blood trauma. So tertiary survey, what, when, why, and how do we do it? And why is it important? Detecting missed injuries is one of the difficult challenges in managing the multi-injured trauma patient, especially the patient who doesn't speak to you or can't speak to you because either they have significant head injury or they are unable to verbalize because of medications that they may be receiving. This is just the sample tertiary survey. It is a head-to-toe exam. You collect the information as far as the physical exam and take more time and usually is performed by an advanced provider. The other is you go through all the films and look specifically for a particular injury and you correlate your exam with the radiological findings, as well as follow through all the various laboratory to make sure that nothing was missed. Why perform a tertiary survey? Well, because sometimes anywhere between as small as 9% to up to 65% of blood trauma, there are missed injuries. They can be usually extremity injuries, both head and neck and spinal have been demonstrated. Factors that are usually associated with this are because your patient may have altered level of consciousness. They may not tell you that they have extremity pain or soreness. They also may be under the influence of drugs or alcohol or they may be under sedated, intubated and unable to communicate. There may be neighboring distraction injuries such as a femur fracture versus an injury to a ligament injury to a knee or something like that. System factors contribute to the missed injury rate. Clinical radiology assessment can contribute. Clinically significant missed injuries were detected usually within 24 hours of admission or should be identified within 24 hours of admission, but the implementation of standardized tertiary surveys has reduced significant injuries. Formal tertiary surveys are performed usually at the bedside by critical care nurses or advanced practice nurses and sometimes by the actual physician team members. Multi-injured patients are the ones that we need to focus and further evaluate and provider skills that most of these folks have are necessary to identify the injuries. Care continuity detects subtle changes that may indicate missed injuries and their sequelae. A designated trauma team member should have advanced assessment skills, not only to review a physical exam, repeat the exam and review imaging. A trauma nurse practitioner is typically well-trained for this endeavor. So trauma resuscitation and exactly what does that mean? Damage control resuscitation usually starts in the pre-hospital setting. Patient may or may not actually get some additional fluid. There may be placement of a tourniquet. There may be external control of non-cavitory bleeding. In the emergency department, the patient arrives and resuscitation begins, access is placed. They may end up starting additional medications as well as blood resuscitation. Patient may go to the operating room where they undergo control of hemorrhage and restoration of appropriate flow, yet the ischemia, reperfusion and the inflammatory process associated with trauma can have various fluid shifts as well as continued oozing and or bleeding requiring further resuscitation, all of which may be requiring the patient returned to the operating room for more definitive repair of multiple injuries. So what are the various damage control procedures that are performed? Although abdomen is what was initially described both with packing and placement of packs within the retroperitoneum, but intrathoracic packing has been described as well. C-clamped and external fixation of pelvic fractures, open book pelvic fractures have been described for many years, yet this is still I think an important recognition that this is an extension of damage control. The secondary of damage control beyond abdominal that was also applied were the use of external extremators, external extremity fixation devices on the extremities. Delayed interventions and mortality and trauma in the setting of damage control contributes to mortality. Mortality is increased in patients who undergo delayed vascular interventions. Those that require unplanned re-exploration or re-exploration for hemorrhage. High-risk motor vehicle crash are at-risk mechanisms that require your increased sensitivity to be able to identify those who are likely to undergo major or have suffered major injury. High-risk auto crashes including intrusion, ejection, if there's been a death in the same vehicle, rollover without restraint, auto versus pedestrian if the bicyclist has been thrown to some degree or run over, and then of course motor crash or motor scooter accidents. Patients with a head injury, it is important to initially stabilize them and make sure that proceed to get an early CT scan. Appropriate resuscitation includes IV access as well as further management. Once cervical spine has been determined not to be injury, elevating their head to 30 degrees is an important component. Treat any pneumothorax and any additional bleeding. The direct negative impact on outcomes is associated with hypoxia or hypotension. Spinal cord injury is also a major injury after intracranial injury. Spine is always considered unstable until it's been demonstrated to be radiographically negative or clinically cleared on exam. Falls are a major risk. We've been seeing this as more trauma patients with falls and older patients after falls are coming more to the trauma center. Exposure to blast also another category. From the 2016 NTDB or National Trauma Data Bank, we've noted that falls have significantly continued to improve. Also, the geriatric patient population mortality has continued to rise. Falls became the number one mechanism of injury, even going past motor vehicle traffic accidents. The other is the level of fatality associated with the mechanisms of injury. Even though falls are number one, followed by a motor vehicle crash, if your injury is related to firearms, the odds are that your mortality was higher. Geriatric trauma is now slowly becoming its own discipline within trauma care. The geriatric patient population of today wants to be able to do everything they were doing before, as such, increasing the risk of potential injury. Geriatric trauma, the majority of these are falls. There are some motor vehicle crash, about almost a quarter of the trauma patient population, and thankfully, penetrating injury remains low. Our second question, 65-year-old male found down at the bottom of the stairs with a scalp laceration. He has a systolic blood pressure of 110, heart rate of 100, respiratory rate of 18, and a Glasgow Coma Scale of 8. Patient's best chance to decrease secondary brain injury is intubation for RSI. We want to make sure that the patient does not get hypoxic. The Stop the Bleed campaign by the American College of Surgeons, after the Sandy Hook injuries, recognized that the majority of the injuries could have been potentially saved if someone had placed a tourniquet. Since then, that's been a major focus. Damage control resuscitation is a systematic approach to the management of the trauma patient with severe injuries. It starts in the emergency department with continued through the operating room or the ICU. The goal here is to allow permissive hypotension, hemostatic resuscitation, vascular damage control techniques, and abdominal compartment syndrome. We do not use damage control resuscitation and head injury as the management of these patients are associated primarily with managing hypoxia, hypotension, and correcting any other factors associated with that. The findings of the Massive Transfusion Protocol, or the PROPR study, demonstrated that the use of blood products in a particular ratio benefited outcome. Out of 680 patients, 613 underwent surgical procedure. There are 397 who underwent laparotomy and 346 who underwent emergency laparotomy. Those requiring emergency laparotomy, 51% versus 50% were resuscitated with a one-to-one to one component therapy versus one-to-one to two. Median time in the laparotomy was 28 minutes, and both survival to 24 hours and 30 hours were similar between treatment arms. 24-hour survival, 86% for the one-to-one to one and 83% for the one-to-one to two. Versus a 30-day survival, 80% one-to-one to one and 75% one-to-one to two. So TAG or Rotem, this is the cartoon of the TAG result, has been used primarily for the assessment of the deficiency in coagulation cascade in the trauma patient. The TAG process can define the area of deficiency associated with coagulation. It can demonstrate that there may be some potential ideologies associated with inadequate coagulation factors, platelet dysfunction or a lack of platelets, as well as the potential for quick and early fibrinolysis that could contribute to plat formation. There are different ways that you can use this to assess. If you are a pattern person, you can actually look at the pattern of the TAG output, and based on that, you can determine where the defects are. You can also, most labs will report the actual laboratory value in numbers, will report the actual laboratory value in numbers, and you can use these to decide which factors to be able to use to correct the coagulopathy. As I mentioned earlier, TXA can be used as well. There is such a thing as primary trauma fibrinolysis, acute coagulopathy of trauma, presence of hyperfibrinolysis and severe trauma injuries are associated with high mortality. The TXA acts to bind to the plasma and block the interaction of plasmidogen to fibrin, preventing the solution of the fibrin clot. Adult trial patients with severe hemorrhagic shock with pressures less than 70 with known predictors of hemolysis or with known fibrinolysis by TXA administer only if less than three hours from time to injury, if one gram IV over 10 minutes and one gram IV over eight hours. The data comes from the CRASH-2 trial, which demonstrated that TXA safely reduced the risk of death in bleeding trial patients. TXA should be considered for use in bleeding trial patients, which, you know, the data comes from the Lancet study. Absence of evidence of TAG or Rotem improves M&M morbidity and mortality from patients with severe bleeding. The application of the TAG or Rotem guide transfusion strategy seems to reduce the amount of products that are used, but whether this has implications on clinical conditions of patients has yet been undetermined, and this is based on the Cochrane study. S-cytoultrasounder point of care is an area that has also been used to be brought to improve the resuscitation of the patient. The transthoracic focus rapid echocardiographic examination can be used to determine moderate versus severe left ventricular dysfunction. It can be used to assess IVC diameter and IVC respiratory variations. The 87% free was able to also answer the clinical question of the primary team. Fractures. Fractures can also be a major cause of bleeding as well as morbidity in trial patients. Obviously, when your patient arrives, it is usually life versus limb, and once we get past the life, we start focusing on limbs. Once we focus on the hemorrhage, and then we can focus on the actual injury that may need to be repaired. A significant bleeding can occur. You can have a single rib fracture and lose 125 cc of blood versus a femur or pelvis fracture where you can have up to class three or four shock. Femur fractures should be reduced to decrease the volume of this potential space within the thigh. One, this helps decrease a lot of the pain associated with a femur fracture, as well as decrease the size of the cone of the thigh where the patient could potentially bleed. Biomechanics of pelvic fractures. Lateral compression injuries can cause significant injuries as well as a particular pattern of injuries. Acute shortening of the diameter across the pelvis rarely destroys ligamentous integrity. Both you and our you do not necessarily want to miss out on a particular type of injury. These can cause significant bleeding. There's quite a few vascular structures within the pelvis, although the bone can bleed after an injury, but there's both arterial and venous structures within the pelvis. Up to 30% of extra pelvic sources can bleed in the chest, abdomen, or multiple extremities. And initially early on, you can trust that over 30 plus percent of the injuries can result in significant bleeding requiring intervention. The damage control orthopedics strategy that focuses on managing and stabilizing major orthopedic injuries and select polytrial patients who are too unstable. Our priorities are control hemorrhage, a provisional stabilization of the major skeletal fractures, and managed soft tissue injuries, minimizing the degree of surgical insult to the patient. Damage control orthopedics stopped ongoing damage, stabilized long bones, stabilized pathophysiology. Our last question, patient is 34 years, status post-motor cycle crash, presents with a hypotension of 90, heart rate of 130, respiratory rate of 30 with a left open femur fracture with exposed bone. The next best step is intubation, follow primary survey, place left lower extremity and skeletal traction, start prophylactic antibiotics. And this one is B, follow primary survey pathway. So in conclusion, ATLS remains unchanged. Airway, breathing, circulation, disability, and exposure. Make sure to follow up on your secondary survey and your tertiary survey. Damage control surgery is the management in patients in hemorrhagic shock. This is coupled with damage control resuscitation. Management of the various different types of injuries is important. Orthopedic damage control is something that is also bookend to the damage control surgery. Well, thank you very much for the opportunity to give you this lecture. Thank you.

monitoring

stabilization

trauma patients

penetrating trauma cases

primary survey

hemostasis

resuscitation

head injuries