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Major Trauma Management and Trauma Team Roles

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Major Trauma Management and Trauma Team Roles

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Major Trauma Management and Trauma Team Roles

  1. 1. Major Trauma Management and Trauma Team Roles Dr Christopher Moseley CME Teaching 8th September 2016
  2. 2. Objectives • Definition • State Trauma Network • Trauma Calls • Team Roles • Trauma mindset • Major Hemorrhage Protocol
  3. 3. Trauma Definition • A term derived from the Greek for “WOUND” • It refers to bodily injury. • It defined as tissue injury due to direct effects of externally applied energy. Energy may be mechanical, thermal, electrical, electromagnetic or nuclear. • Includes: burns, drowning, smoke, inhalation and fall. • Excludes: poisoning/toxic ingestion.
  4. 4. Trauma Definition Major trauma — ‘multiple trauma’ — refers to major injury affecting more than one body system. It can also be defined as an Injury Severity score > 15.
  5. 5. Trauma in Australia Trauma accounts for: • 7.5% of total deaths • 5.5% of hospitalisations • 7% of the total burden of disease in Australia * (Australian Institute of Health and Welfare, 2008).
  6. 6. WA Trauma Network
  7. 7. WA Trauma NetworkTrauma at Charles
  8. 8. Trauma at Charles
  9. 9. WA Trauma Network TRIMODAL DISTRIBUTION OF TRAUMA DEATHS. First Peak – Seconds to minutes (50% all deaths) Second Peak – Minutes to hours. This is why we do what we do as this is where we save lives Third Peak – Days to weeks
  10. 10. Major Trauma Code 10 minutes
  11. 11. What now? Preparation, triage and activation of the trauma resuscitation team
  12. 12. Recognize your in it!
  13. 13. PEOPLE PLACE EQUIPMENT AND DRUGS
  14. 14. People 1) Clear roles and organization 2) Effective communication 3) Support from other hospital areas, transfer services and trauma centres
  15. 15. WA Trauma Network
  16. 16. Trauma Definition • A term derived from the Greek for “WOUND” • It refers to any bodily injury. • It defined as tissue injury due to direct effects of externally applied energy. Energy may be mechanical, thermal, electrical, electromagnetic or nuclear. • Included:burns, drowning, smoke, inhalation and fall. • Excluded: poisoning/toxic ingestion.
  17. 17. Drugs and Equipment Consider what may be required prior to arrival: • Difficult airway trolley • Blood including rapid transfuser • Drugs – e.g analgesia, TXA • IO kit • Procedure kits – chest tubes/thoracotomy kit *USS machine in the bay ready to go
  18. 18. Specialties Specialties may include orthopedics, neurosurgery, cardiothoracics, plastics, ENT and ophthalmology. Early notification of operating theatre staff and ICU is also crucial for critically ill trauma patients. Radiography and radiology staff are a key part of trauma team activation.
  19. 19. https://i.ytimg.com/vi/TQLtISfDxcc/maxresdefault.jpg http://emcrit.org/wee/real-surgical-airway/
  20. 20. HAEMOSTATIC RESUSITATION In the bleeding trauma patient if it doesn’t carry oxygen or it doesn’t clot then use with caution
  21. 21. 1 in 4 trauma patients bleed abnormally The phenomenon of an early coagulopathy in trauma – which goes by many names, including the Acute Coagulopathy of Trauma-Shock (ACoTS) – can occur soon after injury, and is physiologically distinct from the DIC-like phenomenon associated with the “lethal triad” Trauma patients bleed abnormally
  22. 22. Hypothermia Decreases platelet responsiveness, increases platelet sequestration in liver and spleen, reduces Factor function eg Factors XI and XII. Alters fibrinolysis Acidosis pH strongly effects activity of Factors V, VIIa and X. Acidosis inhibits thrombin generation. Cardiovascular effects of acidosis (pH <7.2) – decreased contractility and CO, vasodilatation and hypotension, bradycardia and increased dysrhythmias Lethal Triad
  23. 23. Early hyperfibrinolysis
  24. 24. • Give blood products instead of isotonic crystalloid fluid aiming for limited volume replacement. • Large volume crystalloids can lead to dilutional coagulopathy and exacerbate bleeding. • Crystalloids have no O2 carrying capacity and do little to correct the anaerobic metabolism and O2 debt associated with shock. • Oedema, compartment syndrome, resp distress Blood Vs Crystalloid
  25. 25. Provides resuscitation with blood components resembling whole blood with the aims of: • maintain circulating volume • limit ongoing bleeding • prevent the lethal trial of hypothermia, acidosis and acute coagulopathy of trauma Typical triggers are: • expected or actual haemorrhagic shock • 4 PRBCs administered and instability persists Haemostatic Resusitation
  26. 26. • Involves blood component ratios of 1 or 2 RBCs : 1 FFP : 1 platelets • Rick Dutton freely admits that he made up the ratio of 1:1:1 based in the rationale that it mimics the composition of whole blood • Australian National Guidelines advocates 2:1:1 ratio HOW?
  27. 27. • There is no RCT evidence for RBC:FFP:platelet ratios of 1-2:1:1 versus other ratios/ fluids • The PROPPR trial (2015) found no statistically significant mortality difference on the primary outcome of mortality between massive transfusion protocols based on 1:1:1 and 2:1:1 ratios. There was an absolute difference in mortality of about 4% favouring the 1:1:1 ratio Evidence
  28. 28. • Other agents may be given based on blood tests: • INR >1.5 – FFP • Hb <100 in an actively bleeding -> PRBCs • Calcium <0.8 - calclium gluconate • Platelets <80 - platelets • platelet dysfunction (e.g. drugs) - platelets Adjuncts
  29. 29. Tranexamic Acid Tranexamic acid (TXA) is an anti-fibrinolytic agent that can/should be used early in the resuscitation of bleeding trauma patients The effect of TXA on mortality in bleeding trauma patients is very time-dependent, conferring a huge survival advantage if given early
  30. 30. Tranexaminc Acid Tranexamic acid (TXA) use is supported by the CRASH2 trial: • a multicenter international RCT • Mortality benefit if given to major trauma patients within 3 hours of injury.
  31. 31. Cryoprecipitate • Fibrinogen is the primary substrate for clot formation (along with platelets) • There is a consistent link between falling fibrinogen and mortality in trauma • The key is to measure and follow serum fibrinogen in bleeding patients – a fibrinogen less than 1.0 g/L identifies a hypofibrinogenemic state, the antidote for which is cryoprecipitate.
  32. 32. Management of Major Trauma, Team roles …and stuff… This Is the sum total of my knowledge on the subject so questions to the boss!

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