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Interuniversitair Postgraduaat Onderwijs Heelkunde
1° - 2° jaars ASO heelkunde
W-J. MetsemakersDienst Traumatologie
UZ Leuven
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Postgraduaat Onderwijs: Traumatologie• Case Presentation
• Shock
• Trauma- Advanced Trauma Life Support (ATLS)- Definitive Surgical Trauma Care (DSTC)
• Surgical techniques- Fasciotomy- Diagnostic peritoneal lavage
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Case presentation• Patient, 40 years
• Motor vehicle accident
• Vital signs:Sat: 88% (15l O2)P: 120/minBP: 100/60mmHg
• Rx cervical spine - pelvis – FAST: negative
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Case presentation
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Case presentation
Chest tube (left).
• Sat: 90% (15l O2)
• P: 100/min
• BP: 90/48mmHg
• ……?
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Case presentation
Hemodynamic unstable!
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Case presentation
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‘’Shock is the manifestation of the rudeunhinging of the machinery of life’’Samuel V. Gross, 1872
Shock
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Modern definition:
Shock consists of inadequate tissue perfusion markedby decreased delivery of required metabolic substratesand inadequate removal of cellular waste products.
Shock
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Classification of shock
• Hypovolemic
• Cardiogenic
• Septic (vasogenic)
• Neurogenic
• Traumatic
• Obstructive
Shock
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Pathophysiology of shock• The initial insult, whether hemorrhage, injury, or infection, initiates both a
neuroendocrine and inflammatory mediator response.
• The physiologic responses to hypovolemia are directed at preservation of perfusion to the heart and brain: - vasoconstriction
- fluid excretion - fluid is shifted into the intravascular space.
• The major mechanisms achieving this response are: - prompt increase in cardiac contractility and peripheral
vascular tone via the - autonomic nervous system- hormonal response to preserve salt and intravascular
volume
Shock
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Pathophysiology of shock• With substantial physiologic compensatory mechanisms for small volume
blood loss, predominantly through the neuroendocrine response, hemodynamics may be maintained compensated phase of shock.
• With continued hypoperfusion often not apparent clinically, cell death and tissue injury are ongoing decompensation phase of shock.
Shock
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Hypovolemic shock• The most common cause of shock in the surgical or trauma patient is loss
of circulating volume from hemorrhage.
• Peripheral vasoconstriction is prominent, although lack of sympathetic effects on cerebral and coronary vessels and local autoregulation promote maintenance of cardiac and CNS blood flow.
Shock
Shock in a trauma patient and postoperative patient should be presumed to be because of hemorrhage until proven otherwise!
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Cardiogenic shock• Cardiogenic shock is defined clinically as circulatory pump failure leading
to diminished forward flow and subsequent tissue hypoxia, in the setting of adequate intravascular volume
• Hemodynamic criteria - sustained hypotension (i.e., SBP<90 mmHg for at
least 30 min)
- reduced cardiac index (<2.2 L/min per square
meter)
- elevated pulmonary artery wedge pressure (>15
mmHg)
• Mortality rates for cardiogenic shock are 50 to 80 percent
Shock
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Cardiogenic shock• Most common cause : acute myocardial infarction (MI)
• Cardiogenic shock complicates 5–10 percent of acute MIs
• The most common cause of death in patients hospitalized with acute MI
• Although shock may develop early after myocardial infarction, it is typically not found on admission
Shock
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Cardiogenic shock: pathophysiology:• The pathophysiology of cardiogenic shock involves a vicious cycle of
myocardial ischemia which causes myocardial dysfunction, which results in more myocardial ischemia.
• When sufficient mass of the left ventricular wall is necrotic or ischemic and fails to pump, the stroke volume decreases.
• Decreased compliance results from myocardial ischemia, and compensatory increases in left ventricular filling pressures progressively occur.
Shock
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Shock
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ShockTable 1. Causes of Cardiogenic ShockAcute Myocardial Infarction
- Pump failureLarge InfarctionSmaller infarction with pre-existing diseaseRight Ventricular failure
- Mechanical complicationsPapillary muscle ruptureVentricular septal defectCardiac ruptureTamponade
Other CondtionsEnd-stage cardiomyopathyMyocarditisDrugs – eg beta-blocker overdoseAortic dissection with acute aortic regurgitationMyocardial contusionLeft ventricular outflow tract obstruction
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Cardiogenic shock: diagnosis:• Confirmation of a cardiac source for the shock requires:
- electrocardiogram
- echocardiography
• Other useful diagnostic tests include chest radiograph, arterial blood gases, electrolytes, complete blood count, and cardiac enzymes.
Shock
Relatively few patients with blunt cardiac injury will develop cardiac pump dysfunction. Those who do generally exhibit cardiogenic shock early in their evaluation.
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Cardiogenic shock: treatment:• Intubation and mechanical ventilation are often required, if only to
decrease work of breathing and facilitate sedation of the patient.
• Treatment of cardiac dysfunction includes maintenance of adequate oxygenation to ensure adequate myocardial oxygen delivery and judicious fluid administration to avoid fluid overload and development of cardiogenic pulmonary edema.
• Cave electrolyte abnormalities and dysrrhythmias
• When profound cardiac dysfunction exists, inotropic support may be indicated to improve cardiac contractility and cardiac output:
- Dobutamine- Dopamine- (Cave Epinephrine)
Shock
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Cardiogenic shock: treatment:
• Patients whose cardiac dysfunction is refractory to cardiotonics may require mechanical circulatory support with an intraaortic balloon pump (IABP). Intraaortic balloon pumping increases cardiac output and improves coronary blood flow by reduction of systolic afterload and augmentation of diastolic perfusion pressure
• Anticoagulation and aspirin are given for acute myocardial infarction
• Additional pharmacologic tools may include the use of: β blockers, nitrates and ACE inhibitors
Shock
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Cardiogenic shock: treatment:• Current guidelines of the American Heart Association (AHA): percutaneous
transluminal coronary angiography (PTCA) for patients with:- cardiogenic shock- ST elevation (left bundle-branch block)- age younger than 75 years
• Early definition of coronary anatomy and revascularization is the pivotal step in treatment of patients with cardiogenic shock from acute MI. When feasible, PTCA (generally with stent placement) is the treatment of choice
• Coronary artery bypass grafting (CABG) seems to be more appropriate for patients with multiple vessel disease or left main coronary artery disease
Shock
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Septic (vasogenic) shockIn vasodilatory shock, hypotension results from failure of the vascular smooth muscle to constrict appropriately.
Vasodilatory shock is characterized by both peripheral vasodilatation with resultant hypotension, and resistance to treatment with vasopressors.
The most frequently encountered form of vasodilatory shock is septic shock.
Other causes of vasodilatory shock include: - hypoxic lactic acidosis- carbon monoxide poisoning- decompensated and irreversible hemorrhagic shock- terminal cardiogenic shock- postcardiotomy shock
Shock
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Septic (vasogenic) shock• In the attempt to eradicate the pathogens, the immune and other cell types
elaborate soluble mediators that enhance macrophage and neutrophil killing effector mechanisms, increase procoagulant activity and fibroblast activity to localize the invaders, and increase microvascular blood flow to enhance delivery of killing forces to the area of invasion
• These findings include enhanced cardiac output, peripheral vasodilation, fever, leukocytosis, hyperglycemia, and tachycardia nitric oxide (NO)
Shock
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Septic (vasogenic) shock: diagnosis:• Patients with sepsis have evidence of an infection and systemic signs of
inflammation (e.g., fever, leukocytosis, and tachycardia).
• Recognizing septic shock begins with defining the patient at risk.
• The clinical manifestations of septic shock will usually become evident and prompt the initiation of treatment before bacteriologic confirmation of an organism or the source of an organism is identified.
• These should prompt an aggressive search for infection including:- thorough physical exam- inspection of all wounds- evaluation of intravascular catheters or other foreign bodies- obtaining appropriate cultures and adjunctive imaging studies as needed
Shock
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Septic (vasogenic) shock: treatment:• Evaluation of the patient in septic shock begins with an assessment of their
airway and ventilation Intubation
• Because vasodilation and decrease in total peripheral resistance may produce hypotension, fluid resuscitation is essential
• Empiric antibiotics must be chosen carefully based on the most likely pathogens. Antibiotics should be tailored to cover the responsible organisms once culture data are available
• Intravenous antibiotics will be insufficient to treat the infection in the settings of infected collections, foreign bodies, and devitalized tissue Surgery
• After first-line therapy vasopressors may be necessary to treat patients with septic shock
Shock
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Neurogenic shock• Neurogenic shock refers to diminished tissue perfusion as a result of loss
of vasomotor tone to peripheral arterial beds.
• Sympathetic input to the heart and input to the adrenal medulla may also be disrupted preventing the typical reflex tachycardia that occurs with hypovolemia.
• Neurogenic shock is usually secondary to spinal cord injuries from vertebral body fractures of the cervical or high thoracic region that disrupt sympathetic regulation of peripheral vascular tone.
Shock
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Neurogenic shock: diagnosis:• Acute spinal cord injury may result in bradycardia, hypotension, cardiac
dysrhythmias, reduced cardiac output, and decreased peripheral vascular resistance.
• The classic description of neurogenic shock consists of:
- decreased blood pressure associated with bradycardia
- warm extremities
- motor and sensory deficits indicative of a spinal cord injury
- radiographic evidence of a vertebral column fracture.
Shock
In the multiply injured patient, other causes of hypotension including hemorrhage, tension pneumothorax, and cardiogenic shock must be sought and excluded!!!
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Neurogenic shock: treatment:• After the airway is secured and ventilation is adequate, fluid resuscitation
and restoration of intravascular volume will often improve perfusion in neurogenic shock.
• Administration of vasoconstrictors will improve peripheral vascular tone, decrease vascular capacitance, and increase venous return.
• Specific treatment for the hypotension is often of brief duration, as the need to administer vasoconstrictors typically lasts 24–48 hours.
Shock
First exclude hypovolemia as the cause of the hypotension.
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Traumatic shock• The systemic response after trauma, combining the effects of soft-tissue
injury, long-bone fractures, and blood loss, is clearly a different physiologic insult than simple hemorrhagic shock.
• The hypoperfusion deficit in traumatic shock is magnified by the proinflammatory activation that occurs following the induction of shock.
• Treatment of traumatic shock is focused on correction of the individual elements to diminish the cascade of proinflammatory activation, and includes prompt control of hemorrhage, adequate volumeresuscitation to correct oxygen debt, débridement of nonviable tissue, stabilization of bony injuries, and appropriate treatment of soft tissue injuries.
Shock
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Obstructive shock• Commonly mechanical obstruction of venous return in trauma patients is
because of the presence of tension pneumothorax and cardiac tamponade.
• With either cardiac tamponade or tension pneumothorax, reduced filling of the right side of the heart from either increased intrapleural pressure secondary to air accumulation or increased intrapericardial pressure results in decreased cardiac output associated with increased central venous pressure.
Shock
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Obstructive shock• The diagnosis of tension pneumothorax should be made on clinical
examination.
• The classic findings include:
- respiratory distress
- hypotension
- diminished breath sounds over one hemithorax
- hyperresonance to percussion
- jugular venous distention
- shift of mediastinal structures
Shock
Treatment with pleural decompression is indicated rather than delaying to wait for radiographic confirmation.
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Obstructive shockCardiac tamponade results from the accumulation of blood within the pericardial sac, usually from penetrating trauma or chronic medical conditions.
Triad of Beck consists of hypotension, muffled heart tones, and neck vein distention.
Patients who present with circulatory arrest from cardiac tamponade require emergency pericardial decompression, usually through a left thoracotomy.
Echocardiography has become the preferred test for the diagnosis of cardiac tamponade.
Shock
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Obstructive shockPericardiocentesis to diagnose pericardial blood and potentially relieve tamponade may be used. An in-dwelling catheter may be placed for several days in patients with chronic pericardial effusions.
Diagnostic pericardial window represents in chronic cases the most direct method to determine the presence of blood within the pericardium. The procedure is best performed in the operating room under general anesthesia.
Shock
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• The Advanced Trauma Life Support (ATLS) course of the American College of Surgeons Committee on Trauma was developed in the late 1970s, based on the assumption that appropriate and timely care can significantly improve the outcome for the injured patient.
• ATLS provides a structured approach to the trauma patient with standard algorithms of care; it emphasizes the "golden hour" concept that timely prioritized interventions are necessary to prevent death.
Trauma: introduction
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• The initial management of seriously injured patients consists of the primary survey, concurrent resuscitation, the secondary survey, diagnostic evaluation, and definitive care.
• The first step in patient management is performing the primary survey, the goal of which is to identify and treat conditions that constitute an immediate threat to life.
Trauma: introduction
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• The ATLS course refers to the primary survey as assessment of the "ABCs" (Airway with cervical spine protection, Breathing, and Circulation).
• Although the concepts within the primary survey are presented in a sequential fashion, in reality they often proceed simultaneously.
Trauma: introduction
Life-threatening injuries must be identified and treated before advancing to the secondary survey.
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• Assess a patient’s condition rapidly and accurately.
• Resuscitate and stabilize patients according to priority.
• Determine whether a patient’s needs exceed a facility’s resources and/or a doctor’s capabilities.
• Arrange appropriately for a patient’s interhospital or intrahospital transfer (what, who, when, and how).
• Ensure that optimal care is provided and that the level of care does not deteriorate at any point during the evaluation, resuscitation, or transfer processes.
Trauma: introduction
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• Airway maintenance with cervical spine protection assessment of a free airway so oxygen can be transported
• Breathing and ventilation Without adequate air intake there is no oxygen for transport
• Circulation with hemorrhage control Circulating volume and heart need to be intact to transport oxygen to the brain and the tissues
• Disability: Neurologic status Check the neurological status of the patient
• Exposure/ Environment control: Completely undress the patient, but prevent hypothermia Keep the patient warm and save
Trauma: introduction
Treat first what kills first!
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Trauma: introductionTable 7-1 Immediately Life-Threatening Injuries to Be Identified during the
Primary Survey
Airway
Airway obstruction
Airway injury
Breathing
Tension pneumothorax
Open pneumothorax
Flail chest with underlying pulmonary contusion
Circulation
Hemorrhagic shock
Massive hemothorax
Massive hemoperitoneum
Mechanically unstable pelvis fracture
Extremity losses
Cardiogenic shock
Cardiac tamponade
Neurogenic shock
Cervical spine injury
Disability
Intracranial hemorrhage/mass lesion
‘Blood on the floor….plus four more (chest, abdomen, pelvis, femur)’
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AIRWAY MANAGEMENT WITH CERVICAL SPINE PROTECTION• Ensuring a patent airway is the first priority in the primary survey.
• Simultaneously, all patients with blunt trauma require cervical spine immobilization until injury is excluded.
• In general, patients who are conscious, do not show tachypnea, and have a normal voice do not require early attention to the airway.
• In the comatose patient, the tongue may fall backward and obstruct the hypopharynx; this may be relieved by either a chin lift or jaw thrust.
Trauma: introduction
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Trauma: introduction
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AIRWAY MANAGEMENT WITH CERVICAL SPINE PROTECTION• Options for endotracheal intubation include: - nasotracheal route
- orotracheal route
- surgical routes
• Orotracheal intubation is the most common technique used to establish a definitive airway
• Because all patients are presumed to have cervical spine injuries, manual in-line cervical immobilization is essential
• Patients in whom attempts at intubation have failed or who are precluded from intubation due to extensive facial injuries require surgical establishment of an airway Cricothyroidotomy
Trauma: introduction
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Trauma: introduction
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BREATHING AND VENTILATION• Once a secure airway is obtained, adequate oxygenation and ventilation
must be assured
• All injured patients should receive supplemental oxygen and be monitored by pulse oximetry
• The following conditions constitute an immediate threat to life due to inadequate ventilation and should be recognized during the primary survey: - tension pneumothorax
- open pneumothorax
- flail chest with underlying pulmonary contusion
Trauma: introduction
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CIRCULATION WITH HEMORRHAGE CONTROL• An initial approximation of the patient's cardiovascular status can be
obtained by palpating peripheral pulses.
• In general, systolic blood pressure (SBP) must be:
- 60 mmHg for the carotid pulse to be palpable
- 70 mmHg for the femoral pulse to be palpable
- 80 mmHg for the radial pulse to be palpable
Trauma: introduction
Any episode of hypotension (defined as a SBP <90 mmHg) is assumed to be caused by hemorrhage until proven otherwise
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CIRCULATION WITH HEMORRHAGE CONTROL• IV access for fluid resuscitation is obtained with two peripheral catheters,
16-gauge or larger in adults
• Blood should be drawn simultaneously and sent for measurement of hematocrit level, as well as for typing and cross-matching
• If peripheral access with large-bore angiocatheters is inadequate different options are possible: - central venous line
- saphenous vein cutdowns
- intraosseous needle
Trauma: introduction
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CIRCULATION WITH HEMORRHAGE CONTROL• Cause of bleeding: ‘blood on the floor + 4 more (chest, abdomen, pelvis
femur)’
• Diagnostics: Chest x-ray, x-ray of the pelvis and FAST
Trauma: introduction
Shock in the trauma patient is most commonly due to Hemorrhage.
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Trauma: introduction
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Treatment of hemorrhagic Shock:• First check if A and B are stable
• Check the initial response and act according to the response.
-Rapid response
-Transient response
-Minimal or no response
Trauma: introduction
Stop the bleeding!!!
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Trauma: introduction
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Treatment of hemorrhagic Shock:• Fluid resuscitation begins with a 2 L (adult) or 20 mL/kg (child) IV bolus of
isotonic crystalloid, typically Ringer's lactate.
• For persistent hypotension, this is repeated once in an adult and twice in a child before red blood cells (RBCs) are administered.
• The Urine output is a quantitative, reliable indicator of organ perfusion. Adequate urine output is 0.5 mL/kg per hour in an adult, 1 mL/kg per hour in a child, and 2 mL/kg per hour in an infant <1 year of age.
Trauma: introduction
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DISABILITY AND EXPOSURE• The Glasgow Coma Scale (GCS) score should be determined for all injured
patients
• It is calculated by adding the scores of the best motor response, best verbal response, and eye opening
• Scores range from 3 (the lowest) to 15 (normal)
• Scores of: - 13 to 15 indicate mild head injury
- 9 to 12 indicate moderate head injury
- <9 indicate severe head injury
Trauma: introduction
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Trauma: introduction
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DISABILITY AND EXPOSURE• Establish the patient's: - level of consciousness
- pupil size and reaction
- lateralizing signs
Trauma: introduction
Neurologic evaluation before administration of neuromuscular blockade for intubation is critical!
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• in 85% of all trauma
• often appear dramatic, rarely cause immediate threat to life or limb
• correct assessment prevent later mortality-morbidity
• injury ~ energy
• 1st ABCDE
• Primary and secondary survey
• continuous re-evaluation!
Musculoskeletal trauma
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Definitive Surgical Trauma Care
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Case presentation
‘MIST’ Handover
• M: Mechanism
• I: Injuries sustained
• S: Signs on scene
• T: Treatment
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Case presentation
Left chest tube –minimal drainage
Transfer to O.R. 10h30
Urgent laparotomy
Senior help available
•Chief of Surgery
•Chief of Anaesthesiology
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Case presentation
Operative findings• Distal stomach “doubtful viability”
• Transection of transverse colon
• Multiple small bowel perforations (6)
• Mesenteric lacerations
• Lacerations of left lobe of liver
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Case presentation
Haemodynamically“stable”
•P 110/m BP 110/60 T 32.8 C
Gases –“reasonable”
•O2 saturation 94%
•pH 7.23
•Lactate 6
Oozing; not actively bleeding
• 8 units PRBC transfused
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Case presentation
• Distal gastrectomy
• Multiple small bowel resections
• Liver lacerations repaired
• Resection of transverse colon
• Colostomy
• Operating time: 150 min
Patient becomes suddenly hypotensive!
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Case presentation
Trans-diaphragmatic pericardial assessment
•Pericardial window. No tamponade
Transferred to ICU at 15h00
Fluids given in the ICU
•Colloid 3.5 litres
•Crystalloid 5 litres
•32 units blood
•12 Fresh frozen plasma (FFP)
•10 units platelets
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Case presentation
Bleeding from colostomy
Liver CT scan – no active bleeding
Diffuse intravascular coagulopathy (DIC)
Died 2 days later: multi-organ failure!
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Case presentation
Despite good „surgical technique‟, patient diedWhy?.......
•Failure in decision making
•Failure to know when to stop (gastrectomy, colon
resection, etc)
Appreciate the physiology! Damage control!
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Damage Control Surgery
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Definition
DCL is an abbreviated resuscitative surgical
approach with the primary goal being the rapid
control of hemorrhage and contamination focused
on restoring normal physiology.
Rotondo MF, et al. ‘Damage control’: an ap- proach for improved survival in
Exsanguinating penetrating abdominal injury. J Trauma. 1993;35:375–382.
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Five stages
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Stage I: Patient selectionCritical factors (The deadly triad)•Hypothermia : Tº < 35°C•Severe metabolic acidosis
•pH < 7.2•Lactate > 5 mmol/l
•Coagulopathy (INR or PTT >50% of normal)•Massive transfusion
Secondary factors•Severe injury•Operating time > 90 minutes
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Stage I: Patient selection
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Stage II: DCS: Thoracic Trauma85% of patients do not require operation (chest Tube)
15% require operation
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Stage II: DCS: Thoracic TraumaIndications Emergency Room Thoracotomy (ERT)
Penetrating injury patient ‘in extremis’:
• Witnessed cardiac arrest with electrical activity
• Hypotension (SBP < 60 mm Hg) not responding to adequate fluid Resuscitation
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Stage II: DCS: Thoracic Trauma
Survival<2%!!!
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Stage II: DCS: Thoracic TraumaERT: technique:Usually through the left chest (anterolateral)
Patient supine, slight rotation
Arm elevated if possible
5th intercostal space (under breast)
Cut down onto rib
Enter chest over the top of the rib
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Stage II: DCS: Thoracic TraumaPericardial Tamponade:
Open pericardium in a cranio-caudal direction
Pitfall: damage to phrenic nerve
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Stage II: DCS: Thoracic TraumaControl of the thoracic aorta:Retract left lung anteriorly
Slide hand around posterior chest wall – lateral to medial along ribs
First tubular structure against tip of fingers is the aorta
Divide overlying pleura transversely
Compress aorta against vertebra or clamp with a vascular clamp
Pitfall:
Confusing aorta and oesophagus
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Stage II: DCS: Thoracic Trauma
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Stage II: DCS: Thoracic Trauma
Further exploration and closure of the chest in the OR!!!
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Stage II: DCS: Abdominal Trauma
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Stage II: DCS: Abdominal Trauma
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Stage II: DCS: Laparotomy
•Scoop out as much blood as possible (Kidney dish (receiver))
•Eviscerate small bowel
•Rapid exploration for massive bleeding
•Pack abdomen as appropriate
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Stage II: DCS: Laparotomy
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Stage II: Haemorrhage control
Bleeding vessels/organs
•Ligate
•Shunt
•Repair
The blood loss is usually underestimated!!!
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Stage II: Haemorrhage control
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Liver Trauma
Generous laparotomy
Be prepared to extend
•Sternotomy
•Laterally -subcostal
Efficient retraction
(Omnitract®, etc.)
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Liver Trauma
FIRST STEP: PUSH (manual compression and rapidcontrol)
Now stop and plan approach!
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Liver Trauma
•Inspect without mobilization
•Compress manually - pack with large packs
•Check for and control other sites of bleeding
•Allow anaesthesiologist to catch up
•Wait at least 10 min
•If no further bleeding
•Remove packs
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Liver TraumaMobilize liver if necessaryAdequate packs (as few as needed for haemostasis)
•Subdiaphragmatic•Subhepatically•Posterior to injured lobe•Beneath ribs or abdominal wall
Restore liver contoursLess effective for left lobePlastic lining of packs unnecessary
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Liver Trauma
Perihepatic packing
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Liver Trauma
No treatment required if bleeding has stopped and patient normotensive
Don‟t probe “soft spots”
If still bleeding Pringle Maneuver
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Liver Trauma
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Liver Trauma
Definitive Packing Indications:
• Developing intraoperative coagulopathy
• Failure to control haemorrhage
• Expanding subcapsular haematoma
• Damage control surgery
• Patient requires transfer
• Retrohepatic caval or other venous injury
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Liver TraumaPack first
•Initial packing
Persistent bleeding•Pringle & direct vision
Remember damage control option•Definitive packing
Consider angiography & embolization
Resection rarely desirable or necessary
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Splenic TraumaNonoperative treatment: growing in popularity (children > 90%)
Success NOT predictable by:•Grade of injury•Size of haemoperitoneum on CT
Risk of failure increases with:•Haemodynamic instability•Vascular blush on contrast CT•Age greater than 55 years
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Splenic Trauma
Operative Management
Packing
Topical haemostasis
•Tachosil®
•Fibrin glue
Argon beam
Partial resection
Mesh
Splenectomy
Bloodless surgery of the spleen possible with warm ischaemia for 1 hour
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Splenic Trauma
Generous access
• Left hand placed on spleen
Full mobilization
•Divide lienocolic lig.
•Divide lienorenal lig.
•Divide lienophrenic lig.
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Splenic Trauma
Mobilize spleen medially
Individual ligation of
•Main vessels
•Vasa brevia
Beware tail of pancreas
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Splenic TraumaBleeding
•From ligated splenic vessels (slipped ligature)
Gastric fistula•Gastric wall necrosis from ischaemia or clamp
Pancreatic fistula•Injury of tail of pancreas
Colonic fistula•Colonic damage during division of lienocolic lig
Diaphragmatic injury (missed)•Close proximity injury
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Splenic Trauma
Preservation of the spleen is possible…..but not in adverse circumstances!Think Damage Control Surgery.
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Pelvic Trauma• Mortality rate of haemodynamically unstable pelvic fractures: 40 –
60 %.
• Anatomical studies have discovered that the veins and the surfaces of the fractures are the major sources of haemorrhage in patients with severe pelvic fractures
5-10 % arterial bleeding!
Pelvic stabilisation: tamponade
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Pelvic Trauma
Treatment • Endorotation legs (open book)
• Pelvic Binder:
The use of the pelvic stabilizer (T-POD) results in a reduced symphyseal diastasis of 60% and a
postive circulatory respons in 80% of the patients (E. Tan, S. Van Stigt, A. Van Vugt.: Injury: 2010).
• Operative management: (- C-clamp)
- External fixation
- Pelvic Packing
(- Definitive fixation)
Controversy about kind and timing of fixation.
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Pelvic Trauma
Preperitoneal Pelvic Packing:• Vertical suprapubic incision
• Approach according to Stoppa
• Dissect as far posteriorly as possible
• Pack from below SI joint outwards
• Close fascia and skin
• Use external fixation or simple anterior ORIF to close and fix the ring
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Pelvic Trauma
Angiographic Embolisation:Angiographic embolization (AE):
- First article published by Margolies 1972 (N Engl J Med).
- Efficacy of AE in controling pelvic arterial hemorrhage: > 90%.
Left inferior vesical artery
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Pelvic Trauma
Treatment
REBOA
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Primary Survey: control hemorrhage:– Deep soft tissue lacerations near major vessels:
PRESSURE
– Long bone fractures (eg femoral: 4U blood loss class III shock)
SPLINTING
- traction-alignement (NOT joints)
- ↓ pain,↓ motion, ° muscle tamponade, prevent further
soft tissue injury
- open fractures: + sterile pressure bandage
Musculoskeletal trauma
Aggressive fluid rescusitation!!!
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Secondary survey: 3 goals:
– Identification of life threatening injury (primary)
– Identification of limb threatening injury (secondary)
– Systematic review to avoid missing diagnosis
(continuous re-eveluation)
Musculoskeletal trauma
Undressed (hypothermia)!!!
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Musculoskeletal Trauma
Save Life Before Limb!!!
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Stage II: Contamination control
Drainage
•No stomas
•Drains where appropriate
Closure
•Staples
•Tape
•Suture
Thorough washout with normal saline!!!
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Stage II: Temporary closure
• “Opsite Sandwich” (“Vacpac”)
• VAC-system (ABThera)
• Tissue closure
Don’t suture sheath until definitive closure!!!
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Stage II: Temporary closure
+ -
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Stage II: Temporary closure
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Stage II: Temporary closure
KCI-ABThera
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Stage III: Restoration of physiology
Objectives:
•Core Temperature > 35°C
•Lactate <2.5 mmol/l
•Coagulation Profile within 20% of normal
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Stage IV: Return to the OR
When to transfer from ICU to OR?
•Prompt transfer is cost-effective
•Premature departure is not!
Ideally within 24 –72 hours!!!
Not too early!(patient/surgeon)
Not too late! (infection)
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ConclusionRecognize those at risk early•Proper damage control early•Abort operation early!
Resuscitate in the I.C.U. early
Angiography with embolization
Work with other disciplines as team
Complete the planned surgery later
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Surgical Techniques
• Fasiotomy of the lower leg
• Diagnostic peritoneal lavage
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Compartment syndrome (CS): diagnosis:
• Pain out of proportion to the apparent injury (passive
stretch of the affected muscles).
• Pressure measurements alone are not reliable to rule out
the diagnosis: 1.) DBP-CP= ‘Delta-P’, 30 mmHg or less
suggests CS
2.) CP higher than 30 mmHg also suggests CS
Surgical Techniques: fasciotomy
Clinical Diagnosis!!!
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Surgical Techniques: Fasciotomy
http://www.youtube.com/watch?feature=player_detailpage&v=6c5r5brMOso
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Surgical Techniques: Fasciotomy
Fasciotomy: closure:
De huid niet primair sluiten!!!
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• Diagnostic peritoneal lavage (DPL) is a highly accurate test for evaluating intraperitoneal hemorrhage or a ruptured hollow viscus.
• It is less frequently today due to the increased use of focused abdominal sonography for trauma (FAST) and helical computed tomography (CT).
Surgical Techniques: DPL
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Surgical Techniques: DPL
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Surgical Techniques: DPL
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Surgical Techniques: DPL
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Surgical Techniques: DPL
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Surgical Techniques: DPL
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Surgical Techniques: DPL
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Surgical Techniques: DPL
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Surgical Techniques: DPL
Aspirate 10ml of ‘gross blood or enteric contents’: positive DPL.
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Surgical Techniques: DPL
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Surgical Techniques: DPL
Criteria for "Positive" Finding on Diagnostic Peritoneal Lavage
• Red blood cell count > 100,000/mL
• White blood cell count > 500/mL
• Amylase level > 19 IU/L
• Alkaline phosphatase level > 2 IU/L
• Bilirubin level > 0.01 mg/dL
or
• Gramstain positive for bacteria
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• De vragen van het examen komen uit de slides en de les
• De 2 video’s kunnen via de video-URL onderaan de site terug gevonden worden op youtube
• Denk bij ATLS voornamelijk aan de hoofdpunten: ABCD en in die volgorde!
• Veel succes
Exameninformatie
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