This document discusses the pathophysiology of trauma and recent advances in trauma management. It covers topics such as acute traumatic coagulopathy, permissive hypotension, haemostatic resuscitation using appropriate blood product ratios, tranexamic acid administration, and lessons learned from military medicine including damage control resuscitation and surgery. Key points emphasized are the early development of coagulopathy in trauma patients, the importance of haemorrhage control over aggressive fluid resuscitation, and initiating treatment strategies aimed at reversing coagulopathy and minimizing blood loss.
Principles of Management of the multiply injured patientCHRIS ALUMONA
The multiply injured or polytraumatised patient is at a greater risk of morbidity and mortality than patients with isolated injuries. This risk is greater than the sum of the risks of their individual injuries. A high index of suspicion is needed to recognise immediately life threatening injuries and promptly address them. The principles of management is captured with the ATLS protocol and every trauma surgeon should be conversant with this indispensable tool.
Principles of Management of the multiply injured patientCHRIS ALUMONA
The multiply injured or polytraumatised patient is at a greater risk of morbidity and mortality than patients with isolated injuries. This risk is greater than the sum of the risks of their individual injuries. A high index of suspicion is needed to recognise immediately life threatening injuries and promptly address them. The principles of management is captured with the ATLS protocol and every trauma surgeon should be conversant with this indispensable tool.
Assessment and management of shock in acute trauma setting based on ATLS recommendations .Lecture given in Trauma update at Perintalmanna on19th August 2014.
Fluid and electrolyte management in surgical patients.KETAN VAGHOLKAR
Fluid and electrolyte management has to be aggressive. It is pivitol in speedy recovery in GI surgery. Changes should be anticipated and treated promptly. A detailed knowledge of this is essential for optimum management especially in the ICU.
ATLS is two days course for those who manage trauma patients. These protocols have been followed by hospitals all over the world to treat trauma patients quickly and efficiently.
This is a presentation which contains basics of polytrauma management,ATLS, triage, critical decision making skills, application of Glasgow coma scale and complications of different management strategies, if not applied properly.
Assessment and management of shock in acute trauma setting based on ATLS recommendations .Lecture given in Trauma update at Perintalmanna on19th August 2014.
Fluid and electrolyte management in surgical patients.KETAN VAGHOLKAR
Fluid and electrolyte management has to be aggressive. It is pivitol in speedy recovery in GI surgery. Changes should be anticipated and treated promptly. A detailed knowledge of this is essential for optimum management especially in the ICU.
ATLS is two days course for those who manage trauma patients. These protocols have been followed by hospitals all over the world to treat trauma patients quickly and efficiently.
This is a presentation which contains basics of polytrauma management,ATLS, triage, critical decision making skills, application of Glasgow coma scale and complications of different management strategies, if not applied properly.
Acute stress disorder (ASD) is a mental disorder that can occur in the first month following a trauma. The symptoms that define ASD overlap with those for PTSD. One difference, though, is that a PTSD diagnosis cannot be given until symptoms have lasted for one month. Also, compared to PTSD, ASD is more likely to involve feelings such as not knowing where you are, or feeling as if you are outside of your body.
How common is ASD?
Studies of ASD vary in terms of the tools used and the rates of ASD found. Overall, within one month of a trauma, survivors show rates of ASD ranging from 6% to 33%. Rates differ for different types of trauma. For example, survivors of accidents or disasters such as typhoons show lower rates of ASD. Survivors of violence such as robbery, assaults, and mass shootings show rates at the higher end of that range.
This PPT describes about the Metabolic response to injury as given in Bailey & Love - 26th edition. It will be very useful for Final year MBBS students.
Holley analyses the cascade of events in bleeding trauma patients leading to Australia's latest evidenced-based guidelines on transfusion protocols in critical bleeding.
Debemos cambiar el paradigma! Para la reanimación del paciente politraumatizado en shock hemorrágico, debemos ser tremendamente cuidadosos y conservadores con el aporte de cristaloides o coloides!
Shock hemorrágico en el paciente politraumatizado, no debe tratarse con fisiológico, Ringer o gelatinas! Mientras más de estos productos reciban, peor pronóstico tiene nuestro paciente.
En este contexto, no debe administrarse nada que no aporte a transportar oxigeno o que colabore con la coagulación!
No más reanimación tipo ATLS, donde se recomendaba 2lt de suero fisiológico y solicitar exámenes para evaluar coagulación y ver necesidad de productos sanguíneos... NO MÁS!!!
Conceptos Claves:
- politraumatizado + shock = hemorrágico (abdomen, tórax, extremidades)
- control anatómico del sangrado es vital!
- no reanimar contra presión arterial, reanimar contra perfusión
- si necesita volumen; aportar fluidos que aporten a la coagulación o a transportar oxígeno
- recuerden calcio y ácido tranexámico
- hosp pequeño, o 1rio o 2ndario: esfuerzos en traslado
- hospital cuidado definitivo: protocolo transfusión masiva, hipotensión permisiva, cirugía control de daño, UCI
This presentation discusses the latest evidence for blood transfusion triggers in the intensive care unit of various clinical condition including severe sepsis, GI bleed, post surgical cases, and post cardiac surgery among other cnditions
Bleeding in paediatric surgery - case presentationsscanFOAM
A talk by Birgitta Romlin at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Delivered in collaboration between scanFOAM, SSAI & SFAI.
Trauma-Induced coagulopathy: Methods, Trigger and Mechanism of Early TIC
< a href="http://www.emergency-live.com
">read on Emergency Live</a>
Trauma is the leading cause of death among people under the age of 44. Hemorrhage is a major contributor to deaths related to trauma in the first 48 h.
Geir Strandenes' talk at The Bick Sick in Zermatt, 2018.
Geir does a tour de force on blood transfusion, its history, physiology, the evidence base and ongoing developments in prehospital transfusion practice in both civilian and military settings. He specifically adresses how to apply principles of damage control resuscitation to remote locations and the introduction of fresh whole blood prehospitally from the point of injury onward.
Geir represents the THOR network (Trauma Hemostasis and Oxygenation Research network) where you can find more information
https://rdcr.org/
Find the rest of the talks from The Big Sick on scanfoam:
https://scanfoam.org/bigsick18/
A brief overview of the potential for biomarkers to impact on sepsis diagnosis and management, looking at recent meta-analysis data on procalcitonin and exploring future options for prognostic and diagnosis markers including metabolomics.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
4. MAJOR TRAUMA CENTRE
• 24
hours a day, fully staffed ED
• Consultant
led trauma team
• Dedicated
trauma theatres & operating lists
• All
major specialties:
• Ortho, general, vascular, neuro, plastics, cardiothoracic, head
& neck, urology
• Interventional
• Anaesthesia
Monday, 21 October 13
radiology
& Critical care
5. • High
volume trauma centres reduce mortality from
major injury by 50%. 1
•
(high volume > 20 cases per week)
• Time
from trauma to definitive surgery /
intervention is the primary determinant of
outcome in major trauma (not time to ED). 2
1. Relationship Between Trauma Center Volume and Outcomes. Nathens A et al, JAMA. 2001;285:1164-1171
2. Resources for Optimal Care of the Injured Patient. American College of Surgeons, 1999
•
Monday, 21 October 13
16. •Define shock
....an abnormality of the circulatory system
that results in inadequate organ perfusion and
delivery of oxygen
•Classify shock
•Haemorrhagic / hypovolaemic
•Cardiogenic
•Obstructive
•Distributive
•Septic
•Neurogenic
Monday, 21 October 13
17. CO = HR x SV
BP = CO x SVR
Monday, 21 October 13
21. Triad of Death
1.Coagulopathy
2.Acidosis
3.Hypothermia
Vicious circle
rather than a triangle
SIRS
CARS
Acute Traumatic
Coagulopathy
25% trauma pts have established coagulopathy (ATC) on presentation
- 4 fold increase in mortality
Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma 2003;54:1127-30.
MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma 2003;55:39-44.
Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, et al. Early coagulopathy in multiple injury: an analysis from the German Trauma
Registry on 8724 patients. Injury 2007;38:298-304.
Monday, 21 October 13
24. FLUIDS
Increasing
evidence for crystalloid
Hyperoncotic
Colloid:
Increased risk AKI
6S STUDY
Increased mortality
CHEST STUDY
Monday, 21 October 13
25. •
June 20th 2013: Joint position statement from FICM, RCOA, ICS, College of EM following
on from European Medicines Agency suspending marketing authorisation for HES due to
risks outweighing any perceived benefits
•
Applies equally to pts with hypovolaemia, hypovolaemic shock, critically ill patients
including those with sepsis, burns, trauma and those undergoing surgery
Monday, 21 October 13
26. EMA DECISION BASIS
•1. Perner A, Haase N, Guttormsen AB, et al. Hydroxyethyl starch
130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med
2012;367:124-34. (6S Study)
•2. Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and
pentastarch resuscitation in severe sepsis. N Engl J Med
2008;358:125-39. (VISEP study)
•3. Myburgh JA, Finfer S, Bellomo R, et al. Hydroxyethyl starch or saline
for fluid resuscitation in intensive care. N Engl J Med 2012;367:1901-11.
(CHEST Study)
Monday, 21 October 13
28. PERMISSIVE HYPOTENSION
•
Fluid resuscitating
•
a patient who is no longer bleeding is easy
•
a patient with ongoing bleeding is much more
complicated: huge potential to make the patient worse your endpoints are much more important
•
Increasingly accepted view that moderate hypotension
(Systolic <90mmHg) in trauma patients without TBI is
sufficient to maintain critical organ perfusion (but pressure =
flow)
•
Resuscitating to >90mmHg runs the risk of clot dislodgment
& vicious circle formation
Monday, 21 October 13
34. RESUSCITATION OF THE
BLEEDING PATIENT
•
Rather than aggressive fluid replacement, the ability to
control ongoing blood loss is one of the most
important determinants in the outcome of a seriously
injured patient.
Hess JR, Holcomb JB, Hoyt DB: Damage control resuscitation:
The need for specific blood products to treat the coagulopathy of trauma.
Transfusion 2006;46:685-6.
Don’t obsess about fluid resuscitation
....control the source of bleeding
Monday, 21 October 13
35. RESUSCITATION
•
Coapulopathy (ATC) occurs much earlier than we thought & is
a major driver
•
Haemorrhage control is the priority
•
Do not delay transfer to place of definitive control transfer but
use with caution
•
Permissive hypotension - arguable for - really relevant to
prehospital
•
Clinical end points of resuscitation are uncertain - we are stuck
with BP (Sys 100; Hb 7-8; plts100; INR<1.5; fibrinogen>1)
Monday, 21 October 13
37. MASSIVE TRANSFUSION
•
emerging opinion that
massive transfusion of red
cells and clotting factors in
trauma patients should be
given in broadly similar
proportions from the
outset
Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al.
The ratio of blood products transfused affects mortality in patients receiving massive transfusions
at a combat support hospital. J Trauma 2007;63:805-13.
Monday, 21 October 13
38. PRBC : FFP : PLTS: CRYO
Borgman MA, Spinella PC, Perkins JG, Grathwohl KW, Repine T, Beekley AC, et al.
The ratio of blood products transfused affects mortality in patients receiving massive transfusions
at a combat support hospital. J Trauma 2007;63:805-13.
Monday, 21 October 13
42. DIAGNOSING
ATC
•It is a nightmare.....blind
•PT & APTT - only describe isolated fragments
of the haemostatic process
•Always delays
•Next set sent before first set back
•If it were easy & quick - decisions about blood
product ratios would not have to be preemptive
Typical example of time to receiving PT result
Monday, 21 October 13
49. TRANEXAMIC ACID
•
Direct trauma causes activation of fibrinolysis
•
CRASH 2 June 2010, The Lancet
•
Over 20,000 pts; 274 hospitals, 40 countries
•
Admin <8hrs from injury:1gm over 10mins & then 1gm
over 8hours
•
Administration of Tranexamic acid reduced the risk of
death in bleeding trauma victims (14.5% vs 16%)
•
No increase in vascular occlusive events
Monday, 21 October 13
51. TRANEXAMIC TIMING
• Early
Rx <1hr from injury:
• Mortality
• Rx
1-3hrs from injury:
• Mortality
• Rx
due to bleeding 5.3% (vs 7.7% placebo)
due to bleeding 4.8% (vs 6.1% placebo)
> 3hrs from injury:
•
Seemed to increase risk of death due to bleeding 4.4%
(vs 3.1% placebo)......Unclear why
Monday, 21 October 13
53. TRANEXAMIC ACID
•
In bleeding trauma victims: Give it!
•
CRASH 2: 32% reduction in death if given <1hr
•
Give it ASAP (<3hrs) :1gm over 10mins (followed by 1gm
over 8hrs)
•
Given early it effects ATC: prevents full activation of fibrinolysis
which once started is difficult to abate
•
Pre hospital care may be where its role is best placed
•
Caution in those who present several hours after injury
Monday, 21 October 13
54. LESSONS FROM
CONTMEPORARY WAR
• Transfusion policies
•Rx blast injury
• Liberal use of tourniquets
•Use of haemostatic
•Joint theatre system
•Critical care air transport
team
•Use of US & IO needles
Monday, 21 October 13
dressings
•PTSD
55. MILITARY APPROACH
• Definitive
care quickly
• Permissive
• Early
hypotension
administration of blood:
• Haemostatic
• High
resus
ratio PRBC : FFP : Plts
• Tranexamic
• Damage
acid
control resuscitation
& surgery (DCR / DCS)
Monday, 21 October 13
56. DIFFERENCES
• Military
• Pre
Mx
& non military
hospital & In hospital
• Penetrating
injuries
• Patients-
Monday, 21 October 13
/ blunt / blast
demographics
57. INCOMPLETELY ANSWERED
QUESTIONS
•
Which patients would benefit most from haemostatic resus?
•
How do we identify them at the outset?
•
What is the optimal ratio PRBCs : FFP : Plts ?
•
Which pts will benefit most from permissive hypotension?
•
Precise indications for recombinant factor VII, tranexamic, cryo,
calcium?
•
Does the storage age of the blood matter?
Monday, 21 October 13
58. CONCLUSION
•
Trauma is a leading cause of death in young people: haemorrhagic shock is the leading
cause of mortality
•
Control of bleeding is paramount: therefore rapid transfer is a priority
•
Permissive hypotension has a role in pre hospital care
•
Coagulopathy develops early & is an independent risk factor for death - aggressive Mx
•
Tranexamic acid should be given early - ideally pre hospital
•
Lessons to be learnt from Military approach - but be objective: different patients, injuries &
situation
•
Haemostatic resus: high ratio of products needed; likely 1:2; who stands to benefit most?
•
Further Evidence base is required
Monday, 21 October 13
59. AIMS
1.What’s important in the early
resuscitative phase?
2.What important in the critical
care in recovery phase?
Monday, 21 October 13
60. • Trauma
World
is a major cause of mortality in <50yrs in Western
• Mortality
due to sustained injuries (early)
• Subsequent
• About
Monday, 21 October 13
immune reactions (late) & resultant MOF
5% trauma patients develop post traumatic MOF
61. TRAUMA & MOF
Endogenous factors susceptibility to MOF
•genetics
•physical condition
Exogenous factors
•Injuries themselves
(1st hit: trauma load)
•Resuscitation strategy &
Surgery
(2nd hit: intervention load)
Organ damage & then failure is due to dysfunctional immune response
Monday, 21 October 13