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Polytrauma- Assessment and management till discharge.pptx

  1. Polytrauma- Assessment and management till discharge (ATLS Recent guideline) Presenter: Dr. Bokinala Naveen Moderator: Dr Saurabh Taneja
  2. • Preparation • Triage • Primary survey • Need for patient transfer • Secondary survey • Adjuncts • Continued post resuscitation monitoring and evaluation • Definitive care
  3. Definition • The term ‘polytrauma’ was first used by Tscherne et al., in 1966 for patients that demonstrated a combination of at least 2 ‘severe injuries of the head, chest or abdomen’, or ‘one of them in association with an extremity injury’. • Trentz in 1999 defined Polytrauma is a syndrome of multiple injuries exceeding a defined severity (Injury Severity Score [ISS] >17) with sequential systemic reactions that can lead to dysfunction or failure of remote organs and vital systems, which have not themselves been directly injured. • Oestern, Hans-Jörg; Trentz, Otmar; Uranues, Selman (2014). General Trauma Care and Related Aspects || Polytrauma: Pathophysiology, Priorities, and Management. , 10.1007/978-3-540-88124-7(Chapter 5), 69–76. doi:10.1007/978-3-540-88124-7_5
  4. Injury severity score Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. The Journal of Trauma. 1974 Mar;14(3):187-196. PMID: 4814394.
  5. Trimodal distribution of trauma deaths (ATLS 10th ed) First Peak • Within minutes • Apnea due to TBI or high spinal cord injury or rupture of the heart, aorta or other large blood vessels. • Very few of these patients survive Second Peak • Minutes to hours • Injuries like SDH/EDH, hemopneumothorax, ruptured spleen, lacerations of the liver, pelvic fractures, and/or injuries associated with significant blood loss. Third peak • Days to weeks • Sepsis and Multiple organ system dysfunctions.
  6. Gunst M, Ghaemmaghami V, Gruszecki A, et al. Changing epidemiology of trauma deaths leads to a bimodal distribution. Proc (Baylor Univ Med Cent), 2010;23(4):349–354
  7. Pre Hospital set up and levels of Trauma centres • The prehospital set up is to notify the receiving hospital before personnel transport the patient from the scene. • This allows for mobilization of the hospital’s trauma team members so that all necessary personnel and resources are present in the emergency department (ED) at the time of the patient’s arrival. • Scoop and run • Multiple vs mass casualty
  8. Pre Hospital phase – admit to Level 1 trauma set up 1. GCS <13 2. Systolic BP <90 3. RR <10 or >29 / needs ventilator support Anatomical injury 1. Penetrating trauma : head, neck, torso and extremities proximal to elbow/knee 2. Flial chest, pelvic fractures 3. 2 or more proximal long bone fractures 4. Proximal amputation (Wrist/Ankle) 5. Crushed, degloved, mangled, pulseless extremity 6. Depressed skull fractures 7. Paralysis
  9. Based on the mechanism of injury & high-energy impact – Transfer to Level 2 trauma setup Falls • Adults > 20 feet or 6 meters (2 stories) • Children >10 feet or 3 meters (2-3 times the height of child) High risk motor vehicle crash • Intrusion, including roof >12 inches from occupant side • Ejection (partial or complete from the vehicle) • Death in same passenger compartment • Vehicle telemetry data consistent with injury Auto vs pedestrian/bicyclist thrown, run over with significant impact (>32kmph) Motor cycle crash >32kmph
  10. Special patient or system considerations Older adults • Risk of injury/death more in age >55 years • Systolic BP <110mmHg in age >55 years • Low impact mechanism (ground-level fall) Patients on anticoagulation are at high risk for bleed after injury Children preferably to a pediatric capable trauma center Burns with trauma to a trauma center or else burns facility Pregnant >20 weeks
  11. Primary Survey Rapid examination to identify and treat life threatening conditions • A – Airway maintenance with C-spine protection • B – Breathing and ventilation • C – Circulation with hemorrhage control • D – Disability and neurological status • E – Exposure/ Environmental control 10 second assessment : Ask the patient to identify himself, name and what happened
  12. A-Airway • Check for airway patency and suction the accumulated secretions/ blood • Inspect for foreign bodies; identify facial, mandibular, and/or tracheal/laryngeal fractures causing airway obstruction. • Hoarseness, subcutaneous emphysema, palpable fracture suggests laryngeal trauma • Patients with facial burns and those with potential inhalation injury are at risk for insidious respiratory compromise. • For this reason, consider preemptive intubation in burn patients.
  13. • Patients with severe head injuries who have an altered level of consciousness or GCS score of 8 or lower usually require the placement of a definitive cuffed airway • Initially, the jaw-thrust or chin-lift maneuver often suffices as an initial intervention. • If the patient is unconscious and has no gag reflex, the placement of an oropharyngeal airway can be helpful temporarily. • Establish a patent airway while restricting cervical spine motion. • Use Cervical collar when necessary
  14. Canadian C-spine rule To be more selective in use of radiography in alert and stable trauma patients. Design: Prospective cohort study conducted from October 1996 to April 1999, sample of 8924 adults (mean age, 37 years) with blunt trauma to the head/neck, stable vital signs, and a GCS of 15. 151 patients had (1.7%) had C-spine injury. The resultant model and final Canadian C-Spine Rule comprises 3 main questions: (1) is there any high-risk factor present that mandates radiography (2) is there any low-risk factor present that allows safe assessment of range of motion (3) is the patient able to actively rotate neck 45 degrees to the left and right? By cross-validation, this rule had 100% sensitivity (95% confidence interval [CI], 98%-100%) and 42.5% specificity (95% CI, 40%-44%) for identifying 151 clinically important C-spine injuries. The potential radiography ordering rate would be 58.2%. The Canadian C-Spine rule of radiography in alert and stable trauma patients. JAMA 2001;286:1841–1848.
  15. NEXUS STUDY Cervical-spine radiography does not need to be performed on selected blunt trauma patients who are awake, alert, non intoxicated, do not complain of midline neck pain, and have no tenderness over the bony cervical spine. • Study population:1000 patients in the UCLA Emergency Medicine Center with a chief complaint of blunt trauma, for whom cervical- spine films were ordered and for whom prospective data questionnaires were completed. • Results: • 27 patients with cervical-spine fracture were among the 974 patients. All 27 patients with fracture had at least one of the following four characteristics: midline neck tenderness, evidence of intoxication, altered level of alertness, or a severely painful injury elsewhere. Three hundred fifty-three of 947 (37.3%) patients without cervical-spine fracture had none of these findings. • Conclusion: Cervical-spine radiology may not be necessary in patients without spinous tenderness in the neck, intoxication, altered level of alertness, or other severely painful injury. Hoffman JR, Schriger DL, Mower W, Luo JS, Zucker M. Low-risk criteria for cervical-spine eadiography in blunt trauma: a prospective study. Ann Emerg Med. 1992 Dec;21(12):1454- 60
  16. Burns • Risk for upper airway obstruction increases with burn size and depth, burns to the head and face, inhalation injury, associated trauma, and burns inside the mouth causing edema and pose a greater risk for airway compromise • Pharyngeal thermal injuries can produce marked upper airway edema, and early protection of the airway is critical. • The clinical manifestations of inhalation injury may be subtle and frequently do not appear in the first 24 hours. • If the provider waits for x-ray evidence of pulmonary injury or changes in blood gas determinations, airway edema can preclude intubation, and a surgical airway may be required.
  17. • Examine the patient’s oropharynx for signs of inflammation, mucosal injury, soot in the pharynx, and edema, taking care not to injure the area further. • A carboxyhemoglobin level greater than 10% in a patient who was involved in a fire also suggests inhalation injury. • Transfer to a burn center is indicated for patients suspected of experiencing inhalation injury; however, if the transport time is prolonged, intubate the patient before transport. • Circumferential burns of the neck can lead to swelling of the tissues around the airway; therefore, early intubation is also indicated for full thickness circumferential neck burns
  18. American Burn Life Support (ABLS) indications for early intubation include: • Signs of airway obstruction (hoarseness, stridor, accessory respiratory muscle use, sternal retraction) • Extent of the burn (total body surface area burn > 40%–50%) • Extensive and deep facial burns • Burns inside the mouth • Significant edema or risk for edema • Difficulty swallowing • Signs of respiratory compromise: inability to clear secretions, respiratory fatigue, poor oxygenation or ventilation • Decreased level of consciousness where airway protective reflexes are impaired • Anticipated patient transfer of large burn with airway issue without qualified personnel to intubate en route
  19. Breathing Look • Rate and depth of respiration • See for engorged neck veins • Tracheal deviation • U/L and B/L chest movements • Use of accessory muscles Listen • Chest bilaterally • Hoarseness • Dysphonia Feel • Chest for dullness (hemothorax) or hyper- resonance(pneumothorax) • Crepitus(Emphysema) • Deformity
  20. Tension pneumothorax • Tension pneumothorax develops when a “one-way valve” air leak occurs from the lung or through the chest Wall. • Air is forced into the pleural space with no means of escape, eventually collapsing the affected lung. • Chest pain, Air hunger, Tachypnea, Respiratory distress, Tachycardia, Hypotension, Tracheal deviation away from the side of the injury, Unilateral absence of breath sounds, Elevated hemithorax without respiratory movement, Neck vein distention Cyanosis (late manifestation)
  21. • The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung. • Shock results from marked decrease in venous return, causing a reduction in cardiac output • A simple pneumothorax can be converted to a tension pneumothorax when a patient is intubated and positive pressure ventilation is provided before decompressing the pneumothorax with a chest tube. • Needle decompression (5th ICS anterior to MAL) converts tension pneumothorax to a simple pneumothorax and ICD to be placed as early as possible • Tension pneumothorax can be managed initially by rapidly applying the finger decompression technique.
  22. Flail chest • When a segment of the chest wall does not have bony continuity with the rest of the thoracic cage. • This condition usually results from trauma associated with multiple rib fractures (i.e., 2 or more adjacent ribs fractured in 2 or more places), although it can also occur when there is a costochondral separation of a single rib from the thorax • Decreased respiratory effort, combined with contusion and atelectasis, may limit movement of the chest wall • Definitive treatment is oxygen therapy, adequate ventilation, and cautious fluid resuscitation. • Analgesia with IV narcotics or local anesthetic administration • Options for administering local anesthetics include intermittent intercostal nerve block(s) and transcutaneous intrapleural, extrapleural, or epidural anesthesia.
  23. Open Pneumothorax • Large injuries to the chest wall that remain open results in an open pneumothorax(sucking chest wound). • Equilibration between intrathoracic pressure and atmospheric pressure is immediate. • Air tends to follow the path of least resistance, when the opening in the chest wall is approximately two-thirds the diameter of the trachea or greater, air passes preferentially through the chest wall defect with each inspiration. • Effective ventilation is impaired, leading to hypoxia and hypercarbia. • The clinical signs and symptoms are pain, difficulty breathing, tachypnea, decreased breath sounds on the affected side, and noisy movement of air through the chest wall injury.
  24. • Close the defect with a sterile dressing large enough to overlap the wound’s edges. • Any occlusive dressing (e.g. plastic wrap or petrolatum gauze) may be used as temporary measure to enable rapid assessment to continue. • Tape it securely on only three sides to provide a flutter-valve effect • As the patient breathes in, the dressing occludes the wound, preventing air from entering. During exhalation, the open end of the dressing allows air to escape from the pleural space. • Taping all four edges of the dressing can cause air to accumulate in the thoracic cavity, resulting in a tension pneumothorax unless a chest tube is in place. • Place a chest tube remote from the wound as soon as possible. Subsequent definitive surgical closure of the wound is frequently required.
  25. Circulation- Shock • Any injured patient who is cool to the touch and is tachycardic should be considered to be in shock until proven otherwise • Identify the probable cause of shock and adjust treatment accordingly • Check peripheral pulses, heart rate, BP, pulse pressure, capillary refill, cyanosis • Most injured patients have hypovolemic shock due to blood loss • Shock may be either hemorrhagic or non hemorrhagic • 2 large bore peripheral IV’s (at least 18 gauge) and control bleeding
  26. Focused Assessment with Sonography for Trauma (FAST & eFAST)
  27. Look for blood : 4 places other than floor A. The chest B. The abdomen C. The pelvis and retroperitoneum D. Major long bones and soft tissues. • C • B • D`2
  28. Hemorrhagic shock • Hemorrhage is the most common cause of shock in trauma patients. • The trauma patient’s response to blood loss is made more complex by fluid shifts among the fluid compartments in the body, particularly in the extracellular fluid compartment. • Soft tissue injury, even without severe hemorrhage, can result in shifts of fluid to the extracellular compartment. • The response to blood loss must be considered in the context of these fluid shifts. Also consider the changes associated with severe, prolonged shock and the pathophysiologic results of resuscitation and reperfusion. Hemorr hagic Shock
  29. Initial Resuscitation
  30. Cardiogenic Shock • Cardiac injury, cardiac tamponade, an air embolus, or, rarely, myocardial infarction may cause • Suspect a blunt cardiac injury when the mechanism of injury to the thorax involves rapid deceleration. • All patients with blunt thoracic trauma need continuous electrocardiographic (ECG) monitoring to detect injury patterns and dysrhythmias. • The shock state may be secondary to myocardial infarction in the elderly and other high-risk patients, such as those with cocaine intoxication. • Cardiac enzyme levels may assist in diagnosing and treating injured patients in the emergency department (ED), as acute myocardial ischemia may be the precipitating event.
  31. Cardiac Tamponade • Cardiac tamponade is most commonly encountered in penetrating thoracic trauma, it can also result from blunt injury to the thorax. • Tachycardia, muffled heart sounds, and dilated, engorged neck veins with hypotension and insufficient response to fluid therapy suggest cardiac tamponade –becks traid (Dilated RA, RV) • Absence of these classic findings does not exclude. • Tension pneumothorax can mimic cardiac tamponade, with findings of distended neck veins and hypotension in both. However, absent breath sounds and hyper-resonant percussion are not present with tamponade. • Echocardiography can be used , FAST to identify pericardial fluid, • Cardiac tamponade is best managed by formal operative intervention, as pericardiocentesis is at best only a temporizing maneuver • Tension pneumothorax
  32. Neurogenic Shock • Isolated intracranial injuries do not cause shock unless the brainstem is injured. • Cervical and upper thoracic spinal cord injuries can produce hypotension due to loss of sympathetic tone • The classic presentation of neurogenic shock is hypotension without tachycardia or cutaneous vasoconstriction. • A narrowed pulse pressure is not seen in neurogenic shock. • The failure of fluid resuscitation to restore organ perfusion and tissue oxygenation suggests either continuing hemorrhage or neurogenic shock. • Advanced techniques for monitoring intravascular volume status and cardiac output may be helpful in managing this complex problem
  33. Massive transfusion 1. Replacement of one entire blood volume within 24 h 2. Transfusion of >10 units of packed red blood cells (PRBCs) in 24 h 3. Transfusion of >20 units of PRBCs in 24 h 4. Transfusion of >4 units of PRBCs in 1 h when on-going need is foreseeable 5. Replacement of 50% of total blood volume (TBV) within 3 h. Definitions of MBT suggested for use in children are • Transfusion of >50% TBV in 3 h, • Transfusion >100% TBV in 24 h or transfusion support to replace on-going blood loss of >10% TBV/min Patil V, Shetmahajan M. Massive transfusion and massive transfusion protocol. Indian journal of anaesthesia. 2014 Sep;58(5):590.
  34. Criteria to trigger the activation of an MTP should include one or more of the following:  Persistent hemodynamic instability  Active bleeding requiring operation or angioembolization  Blood transfusion in the trauma bay If MTP triggers are met: • Begin universal blood product infusion rather than crystalloid orcolloid solutions. • Transfuse universal RBC and plasma in a ratio between 1:1 and 1:2 (plasmato RBC). • Transfuse one single donor apheresisor random donor platelet pool for each six units of RBC. • Blood products should be automatically sent by the transfusionservice in established ratios. • Subsequent coolers should be delivered at 15-minute intervals until the MTP has been terminated. • The goal is to keep at least one MTPcooler ahead for the duration of the MTP activation. ACS TQIP MASSIVE TRANSFUSIONIN TRAUMA GUIDELINES
  35. Endpoints of Transfusion  The ratio-driven massive transfusion may be discontinued or downgraded to goal-directed transfusion based on the laboratory findings if surgical bleeding has been controlled by the surgeon in the operating room OR there is radiographic and physiologicevidence of bleeding control after angioembolization.  The MTP should be discontinued when there is recognition that further resuscitation is futile.  The following should be used as guides to cease therapy with blood and blood components in a patientwho is not actively bleeding and still in the acute resuscitation phase  RBC transfusions for hemoglobin ≥10 g/dL  Plasma transfusion for prothrombin time (PT) <18 seconds  Plasma transfusion for activated partial thromboplastin time (aPTT) <35 seconds  Platelet transfusions for platelet count >1.5 lac/ml  Cryoprecipitate or fibrinogen concentrate for fibrinogen level >180 mg/dL ACS TQIP MASSIVE TRANSFUSIONIN TRAUMA GUIDELINES
  36. • If standard thrombelastography (TEG®) is available, the following cut- points for transfusion triggers may also be used: • Plasma for r-value >9 minutes • Plasma and/or cryoprecipitate (fibrinogen concentrate) for k-time >4 minutes • Cryoprecipitate (or fibrinogen concentrate) and/or plasm for α-angle <60 degrees • Platelets for mA <55 mm • Anti-fibrinolytics for LY30 >7.5 % ACS TQIP MASSIVE TRANSFUSIONIN TRAUMA GUIDELINES
  37. If rapid TEG is available, the following cut-points for transfusion triggers may also be used: • Plasma for ACT >128 seconds • Plasma and/or cryoprecipitate (fibrinogen concentrate) for k- time >2.5 minutes • Cryoprecipitate (fibrinogen concentrate) and/or plasma for α- angle <60 degrees • Platelets for mA <55 mm • Antifibrinolytics for LY30 >3 %
  38. Disability • Level of consciousness, pupillary size and reaction, lateralizing signs and spinal cord injury level ( ability to move all extremities) • Glasco Coma Scale • Careful in head injury patients Exposure • Completely undress the patient and inspect the entire patient from head to toe both front and back • Maintain spinal precautions during logrolling • Inspect both axilla and perineum • Warm blankets.
  39. Secondary survey • The secondary survey does not begin until the primary survey (ABCDE) is completed, resuscitative efforts are underway, and improvement of the patient’s vital functions has been demonstrated • Complete history and physical examination • Reassessment of all vital signs AMPLE History Allergies Medications Past medical history (LMP, transfusions) Last meal Events leading up to trauma
  40. Physical examination • Stepwise, organized • Every patient, the same way, every time • Superior to inferior; proximal to distal • Look--Listen—Feel  Neurologic  Head  Maxillofacial  Cervical spine and neck  Chest  Abdomen  Perineum/rectum/vagina  Musculoskeletal
  41. ADJUNCTS TO SECONDARY SURVEY X ray examination • Haemothorax or simple pneumothorax. • Spine fractures • Rib, Sternum, and Scapular Fractures • Limb fractures • Suspected of having smoke inhalation injury • Appearance of an elevated right diaphragm on a chest x-ray may be the only finding of a right- sided injury.
  42. CT Brain • To rule out head injury
  43. CT scans of head, chest, abdomen and spine Contrast angiography • Contrast-enhanced CT that demonstrates ruptured gastrointestinal tract, intraperitoneal bladder injury, renal pedicle injury, or severe visceral parenchymal injury after blunt or penetrating trauma • Abdominal CT scan with IV contrast can document the presence and extent of a blunt renal injury • Suspected urinary system injuries are best evaluated by CECT. Intravenous pyelogram (IVP) provides an alternative • Some fractures traverse the carotid canals and can damage the carotid arteries (dissection, pseudoaneurysm, or thrombosis. • For detecting fractures of the posterior elements (pedicles, lamina, and spinous processes) and determining the degree of canal compromise caused by burst fractures. • CT angiography may be used to evaluate extremity vascular injuries • Do not perform CT scanning if it delays the transfer of a patient to a higher level of care.
  44. Bronchoscopy • Tracheobronchial injury is a fatal condition • The majority of tracheobronchial tree injuries occur within 1 inch (2.54 cm) of the carina. • High mortality rate from associated injuries, inadequate airway, or development of a tension pneumothorax or tension pneumopericardium • Patients typically present with hemoptysis, cervical subcutaneous emphysema, tension pneumothorax, and/or cyanosis • Smoke inhalation is a potential cause of airway obstruction from particulate and chemical injury. Esophagoscopy for suspected Oesophageal tear/ injury
  45. Course of stay Evaluate and manage • DVT • Infections • Surgical management • Nutritional management • Pain relief • Long term rehabilitation
  46. New recommendations Initial assessment Restriction to only 1 L of crystalloid fluid during initial assessment. Airway & ventilation Drug-assisted intubation has now replaced rapid sequence intubation (RSI). Video laryngoscopy highlighted as useful. Shock Early use of blood products advocated. Tranexamic acid is now recommended within 3 hours. Thoracic trauma Flail chest replaced by tracheobronchial tree injury as a life-threatening injury. 5 th ICS for needle thoracocentesis in adults Modified FAST recommended for identification of pneumothorax. Traumatic circulatory arrest algorithm (thoracotomy/pericardiotomy if no ROSC) Chest size tube smaller 28-32F (previously 36-40F) Abdominal & pelvic trauma Prostate examination no longer recommended as part of the evaluation. Preperitoneal pelvic packing included in hemorrhage protocol.
  47. Head trauma Anticoagulation reversal table is now included in the guidance. Revised version of the GCS introduced. Spine & spinal cord trauma CCR and NEXUS guidelines are now recommended. “Spinal immobilisation” has been replaced with “spinal motion restriction.” Prolonged backboard usage (>2 hours) should be avoided. Musculoskeletal trauma The use of a tourniquet to control severe extremity bleeding is now recommended. Antibiotics dosing regimens for open fractures introduced. Use weight based regimen Thermal injuries New fluid resuscitation formula (2 ml/kg/%TBSA) Paediatric trauma The PECARN traumatic brain injury algorithm now recommended. (CT head- LOC >5sec, abnormal behavior, scalp hematoma, vomiting, headache) Geriatric trauma Lower threshold for imaging in the elderly population is now recommended. High-risk pre-existing conditions highlighted.(Cirrhosis, Coagulopathy, COPD, IHD, DM) Trauma in pregnancy Vaginal fluid pH greater than 4.5 is an indicator of amniotic fluid leakage. Transfer to definitive care CT scans should now be avoided in the primary hospital. SBAR communication tool now recommended.

Editor's Notes

  1. 1 -Head or neck 2-Face 3 -Thorax 4 -Abdomen 5-Extremities 6-External
  2. Patients who were pronounced dead at the scene were considered “immediate” deaths, while those who were transported to the hospital were classifi ed as “early” deaths (≤4 hours from injury) or “late” deaths (>4 hours from injury). Th ose who were transported to the hospital and were pronounced dead on arrival were classifi ed as early deathsstudy population consisted of 678 deaths in Dallas County, 2005 historical group from Trunkey’s 1983 study
  3. In 2010, the National Highway Traffic Safety Administration standardized collision data collected by event data recorders, which may help determine appropriate emergency medical service (EMS) response. Advanced Automatic Collision Notification (AACN) services and event data recorders have become more prevalent in vehicles, capturing collision details, such as change in velocity, principal direction of force, and seat belt use, based on vehicle sensors triggered during airbag deployment. Use of these data in predictive models could help guide the prehospital care of injured occupants, and in 2006, the National Expert Panel included ‘‘vehicle telemetry data consistent with a high risk of injury’’ as part of the triage guidelines
  4. Recreational vehicle – caravan Cross-validation, sometimes called rotation estimation or out-of-sample testing, is any of various similar model validation techniques for assessing how the results of a statistical analysis will generalize to an independent data set.
  5. L=Look externally (facial trauma, large incisors, beard or moustache, and large tongue) E=Evaluate the 3-3-2 rule (incisor distance <3 fingerbreadths, hyoid/mental distance <3 fingerbreadths, thyroid-to-mouth distance <2 fingerbreadths) M=Mallampati (Mallampati score ≥3) O=Obstruction (presence of any condition that could cause an obstructed airway) N=Neck mobility (limited neck mobility). gum elastic bougie
  6. PPVPositive pressure ventilation can exacerbate air leaks and prevent pleural healing, potentially causing a rapid increase in the size and severity of existing pneumothorax
  7. flutter-valve effect it is a one-way valve, thus it prevents the evacuated air from travelling back to the thoracic cavity along the attached chest tube
  8. Focused assessment with sonography for trauma (FAST) should include views of (1) the hepatorenal recess (Morison pouch), (2) the perisplenic area, (3) the subxiphoid pericardial window, and (4) the suprapubic window (Douglas pouch).
  9. Cocaine has multiple cardiovascular and hematologic effects that likely contribute to the development of myocardial ischemia and/or MI. Cocaine blocks the reuptake of norepinephrine and dopamine at the presynaptic adrenergic terminals, causing an accumulation of catecholamines at the postsynaptic receptor and thus acting as a powerful sympathomimetic agent.10,11 Cocaine causes increased heart rate and blood pressure in a dose-dependent fashion.12 In humans, intranasal cocaine use resulted in an increase in heart rate (17±16% beats/min), mean systemic arterial pressure (8±7% mm Hg), cardiac index (18±18% liters/min per m2), and dP/dt (18±20% mm Hg/s).13 The chronotropic effects of cocaine use are intensified in the setting of alcohol use.14 In addition, cocaine administration can reduce left ventricular function and increase end-systolic wall stress.15 By increasing heart rate, blood pressure, and contractility, cocaine leads to increased myocardial demand. Even small doses of cocaine taken intranasally have been associated with vasoconstriction of coronary arteries.16 Coronary vasoconstriction may be more accentuated in patients with preexisting coronary artery disease.17 Many cocaine users tend to be young men who also smoke cigarettes.18,19 The combination of cocaine and cigarette use results in greater increases in heart rate and vasoconstriction than either cocaine use or cigarette smoking alone.20 Vasoconstriction in the setting of cocaine use is most likely secondary to stimulation of the α-adrenergic receptors in smooth muscle cells in the coronary arteries, as pure α-adrenergic antagonists reduce coronary vasoconstriction in cocaine users.20 In addition to α-adrenergic stimulation, cocaine has been shown to increase levels of endothelin-1, which is a powerful vasoconstrictor,21 and to decrease production of nitric oxide, which is a vasodilator.22 Thus, cocaine decreases oxygen supply and induces myocardial ischemia through a variety of mechanisms. Acute thrombosis of coronary arteries shortly after cocaine use has been described.23 The propensity for thrombus formation in the setting of cocaine intake may be mediated by an increase in plasminogen-activator inhibitor.24 Cocaine use has also been associated with an increase in platelet count,25 increased platelet activation,26 and platelet hyper-aggregability.27 Autopsy studies demonstrated the presence of coronary atherosclerosis in young cocaine users along with associated thrombus formation; thus, cocaine use is associated with premature coronary atherosclerosis and thrombosis.28 Cocaine users have elevated levels of C-reactive protein, von Willebrand factor, and fibrinogen that may also contribute to thrombosis.29 Cocaine, therefore, causes myocardial ischemia or MI in a multifactorial fashion that includes: (1) increasing myocardial oxygen demand by increasing heart rate, blood pressure, and contractility; (2) decreasing oxygen supply via vasoconstriction; (3) inducing a prothrombotic state by stimulating platelet activation and altering the balance between procoagulant and anticoagulant factors; and (4) accelerating atherosclerosis.
  10. low blood pressure, distension of the jugular veins and decreased or muffled heart sounds on cardiac auscultation.  ECG criteria of cardiac tamponade we adopted was as follows: 1) Low QRS voltage in a) the limb leads alone, b) in the precordial leads alone or, c) in all leads, 2) PR segment depression, 3) Electrical alternans, and 4) Sinus tachycardia.
  11. DPL aspirate 10ml positive blood for intraperitoneal injury, Insert catheter and lavage Abdome >100000 rbc/mm3 Lower chest >5000-1000 Vegetable or >500 hollow viscous injury
  12. Rapid TEG (r-TEG) utilizes tissue factor instead of the kaolin-cephalin reagent to activate blood coagulation. Because tissue factor triggers the extrinsic coagulation pathway, which involves a smaller number of coagulation factors, the test can be performed faster than conventional TEG
  13. Aggressive fluid resustication (>1.5LIT) causes mortality Name change RSI TO DSI including the landmark CRASH-2 study, tranexamic acid is now recommended within 3 hours at a loading dose of 1 g IV over 10 minutes, followed by 1 g infused over eight hours. In some areas, tranexamic acid is also being used in the pre-hospital setting. T no longer considered an accurate or useful, procedure, the patient was placed supine and a 7–8-cm vertical skin incision was made starting at the symphysis pubis (Fig. 1a). After vertically resecting the anterior sheath of the rectus abdominis muscle and splitting the muscle, the peritoneum was palpated using a fingertip. Blunt dissection was performed through the preperitoneal space in the posterolateral direction to palpate the lateral border of the sacroiliac (SI) joint. Medial migration of the peritoneum with a Deaver retractor was used to improve the operative view where necessary (Fig. 1b). Three surgical laparotomy pads were then packed firmly from the near side of the SI joint using ringed forceps (Fig. 1c). The same procedure was repeated on the contralateral side and skin was approximated with a continuous suture. Then, external fixation was performed according to the orthopedic surgeon’s decision. After PPP, patients were sent to the trauma intensive care unit (TICU) and resuscitation and transfusion were maintained until patients stabilized. After the patient’s coagulopathy was sufficiently corrected, decisions regarding the need for a second operation were made, and if possible, it was performed within 48 h. During the second operation, the packed surgical laparotomy pads were removed and the bleeder was controlled. Then, a closed suction drain was inserted into the preperitoneal space and fascia repair was performed (Fig. 1d). When the amount of drainage decreased below 50 cc, the drain catheter was removed.
  14. 2. risk of skin ulcer formation 3. Pediatric Emergency Care Applied Research Network (PECARN) Airway, Breathing, and Circulationproblems identified and interventions performed •Situation: patient name, age, referring facility, referring physician name, reporting nurse name, indication for transfer, IV access site, IV fluid and rate, other interventions completed •Background: event history, AMPLE assessment, blood products, medications given (date and time), imaging performed, splinting •Assessment: vital signs, pertinent physical exam findings, patient response to treatment •Recommendation: transport mode, level of transport care, medication intervention during transport, needed assessments and interventions