The hypotensive trauma patient

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A look at the hypotensive trauma patient.

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The hypotensive trauma patient

  1. 1. The Hypotensive Trauma Patient<br />By Kane Guthrie<br />
  2. 2. Trauma in WA<br />
  3. 3. But what about SCGH?<br />
  4. 4. The Guide<br />
  5. 5. The Guidelines<br />
  6. 6. The Hypotensive Trauma Patient<br />
  7. 7. Causes?<br />
  8. 8. Case Study<br />
  9. 9. The Approach<br />C :Catastrophic haemorrhage<br />A: Airway > C-spine<br />B: Breathing<br />C: Circulation<br />D: Disability<br />E: Exposure<br />
  10. 10. The Lethal Triad<br />
  11. 11. Surveys<br />Trauma Team<br /><ul><li> Major Trauma Call
  12. 12. ED Trauma Call</li></ul>Primary Survey<br />Secondary Survey<br />
  13. 13. Physical Exam<br />Focus on:<br />ID all sites of external bleeding<br />ID external markers of torso injury<br />ID all penetrating wounds<br />Pearls<br />Roll the patient early<br />Don’t underestimate scalp bleeding<br />
  14. 14. Diagnostic Testing<br />Bedside Testing:<br />AP CXR<br />AP Pelvis x-ray<br />FAST, EFAST<br />DPL is out. <br />Definitive Testing<br />CT scan (Donut of death)<br />Surgical Exploration (Laparotomy, Angio)<br />
  15. 15. Ultrasound<br />FAST &EFAST<br />Extension of physical exam<br />Patient doesn’t have to move to it<br />Looks for free fluid<br />Can also Dx PTX<br />Helpful for vascular access <br />
  16. 16. Pathology<br />Base deficit (VBG,ABG)<br />Haemoglobin<br />Lactate<br />Haematocrit<br />All must be in a series.<br />
  17. 17. Airway<br />Maintaining airway can be difficult R/T:<br />Maxillofacial trauma<br />Neck trauma<br />Laryngeal trauma<br />C-spine precautions<br />Secure airway early<br />
  18. 18. C-Spine<br />Maintain precautions until<br />Nexus Vs Canadian <br />Imaging<br />Clinically<br />
  19. 19. Breathing<br />Give O2 NRBM 15L<br />RSI with in-line stabilization<br />Prepare for difficult airway<br />Beware of pre-existing co-morbidities <br />Avoid hypotension, lower doses, ? use Ketamine<br />
  20. 20. Circulation<br />Don’t rely on HR & BP<br />Place x 2 18g IVC<br />Consider IO early if difficult access<br />U/O and serial lactate guide Mx:<br />Ketamine ?better for intubation/analgesia<br />Fluid resuscitation blood is better<br />Crystalloid Vs Colloid<br />Do Inotropes have a role???<br />
  21. 21. Massive Transfusion<br />Focuses more on blood products than fluids<br />Predicting who needs M/T<br /><ul><li>Penetrating mechanism
  22. 22. SBP <90mmHg
  23. 23. HR >120bpm
  24. 24. Positive FAST abdominal views</li></ul>1:1:1 Ratios (PRBCS, FFP, Platlets)<br />
  25. 25. Trendelenburg Position<br />Time honored tradition <br />Limited evidence (more harm than good)<br />Effects are short lived<br />Complications<br /><ul><li>^ dyspnea, hypoventilation and atelectasis
  26. 26. Abdo organs into chest cavity decreasing venous return to heart
  27. 27. Risk of aspirating gastric contents</li></ul>?Leg elevation better than nothing<br />
  28. 28. Disability<br />TBI<br />ETOH, illicit, Metabolic (BSL),<br />GCS < 8 Intubate??? Prefer GCS <12<br />Maintain adequate perfusion<br />
  29. 29. Exposure<br />Get complete exposure during assess<br />Then:<br />Keep patient warm<br />Give warm fluids<br />Monitor core temp<br />= avoids hypothermia/ lethal triad.<br />
  30. 30. Special Considerations<br />Elderly<br />Athletes<br />Pregnancy<br />Medication <br />Hypothermia<br />Pacemaker<br />
  31. 31. Interventions<br />External <br /><ul><li>Apply direct pressure, Suture Lacerations</li></ul>Long Bone #<br /><ul><li>Splint +/- reduce #</li></ul>Chest<br /><ul><li>ICC, Pigtail</li></ul>Abdomen<br /><ul><li>Emergency Laparotomy</li></ul>Retroperitoneum<br /><ul><li>Externally stabilse pelvis, Emergency Angiogram</li></li></ul><li>Resources<br />www.lifeinthefastlane.com<br />http://emcrit.org/<br />http://www.itim.nsw.gov.au/<br />www.trauma.org/<br />

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