Download - Trauma: The Golden Hour
Trauma:Trauma:The Golden HourThe Golden Hour
Dennis Kim MD Dennis Kim MD FRCS(C)FRCS(C)
General SurgeryGeneral Surgery
Trauma & Critical Care Trauma & Critical Care POS Core POS Core
Lecture SeriesLecture Series
February 17 2009February 17 2009
ObjectivesObjectives
concept of a golden hourconcept of a golden hour
pathophysiology of shock in the pathophysiology of shock in the trauma patienttrauma patient
resuscitation according to ATLS resuscitation according to ATLS principlesprinciples
overviewoverview specificsspecifics
The Golden HourThe Golden Hour
originated by R Adams Cowleyoriginated by R Adams Cowley
first sixty minutes after the first sixty minutes after the occurrence of multi-system traumaoccurrence of multi-system trauma
victim's chances of survival are victim's chances of survival are greatest greatest if they receive definitive if they receive definitive care in the OR within the first hour care in the OR within the first hour after a severe injuryafter a severe injury
The Golden HourThe Golden Hour
recently, the validity of the “golden recently, the validity of the “golden hour” as a rigidly defined timeframe hour” as a rigidly defined timeframe scrutinizedscrutinized
core principle of rapid intervention core principle of rapid intervention in trauma cases remains universally in trauma cases remains universally acceptedaccepted
The Golden HourThe Golden Hour
"There is a golden hour between life "There is a golden hour between life and death. If you are critically injured and death. If you are critically injured you have less than 60 minutes to you have less than 60 minutes to survive. You might not die right then; survive. You might not die right then; it may be three days or two weeks it may be three days or two weeks later -- but something has happened later -- but something has happened in your body that is irreparable."in your body that is irreparable."
- R Adams Cowley- R Adams Cowley
The Golden HourThe Golden Hour
Time and Trauma OutcomesTime and Trauma Outcomes
no convincing studies that time to no convincing studies that time to treatment consistently leads to better treatment consistently leads to better outcomeoutcome
outcome related to many factors outcome related to many factors including reduced time between injury including reduced time between injury and definitive careand definitive care
Ann Surg. 2003;237(2):153-60 Ann Surg. 2003;237(2):153-60
1. What is the most common 1. What is the most common cause of shock in the cause of shock in the trauma patient?trauma patient?
septicseptic
B) cardiogenicB) cardiogenic
C) hemorrhagicC) hemorrhagic
D) neurogenicD) neurogenic
2. The most easily 2. The most easily reversible cause of shock in reversible cause of shock in the trauma patient is:the trauma patient is:
A) hemorrhagicA) hemorrhagic
B) neurogenicB) neurogenic
C) tension pneumothoraxC) tension pneumothorax
D) cardiac tamponadeD) cardiac tamponade
3. The most commonly 3. The most commonly injured solid intraabdominal injured solid intraabdominal organ in blunt trauma is:organ in blunt trauma is:
A) liverA) liver
B) spleenB) spleen
C) kidneyC) kidney
D) small bowelD) small bowel
4. The bloody vicious cycle 4. The bloody vicious cycle of trauma refers to:of trauma refers to:
A) bleeding, hypothermia, and acidosisA) bleeding, hypothermia, and acidosis
B) bleeding, hyperthermia, acidosisB) bleeding, hyperthermia, acidosis
C) transfusion, hypothermia, acidosisC) transfusion, hypothermia, acidosis
D) transfusion, hypothermia, alkalosisD) transfusion, hypothermia, alkalosis
5. Hemorrhagic shock is 5. Hemorrhagic shock is usually caused by bleeding usually caused by bleeding into or from:into or from:
A) abdomenA) abdomen
B) pelvisB) pelvis
C) chestC) chest
D) headD) head
E) all of the aboveE) all of the above
F) A,B,CF) A,B,C
The Golden HourThe Golden Hour
Shock PathophysiologyShock Pathophysiology
inadequate organ inadequate organ perfusionperfusion and and tissue tissue oxygenationoxygenation
3 factors determine:3 factors determine:
1. 1. oxygen contentoxygen content2. 2. oxygen deliveryoxygen delivery3. 3. distribution distribution
The Golden HourThe Golden Hour
Shock PathophysiologyShock Pathophysiology
prolonged hypoperfusion creates a prolonged hypoperfusion creates a vicious cycle of ischemia and shockvicious cycle of ischemia and shock
2 most important steps in managing 2 most important steps in managing shock:shock:
1. recognition1. recognition2. treatment2. treatment
The Golden HourThe Golden Hour
Rapid ResuscitationRapid Resuscitation
restores circulating volumerestores circulating volume improves oxygen deliveryimproves oxygen delivery prevents cellular ischemia and tissue prevents cellular ischemia and tissue
necrosisnecrosis prevents onset of secondary cellular prevents onset of secondary cellular
injuryinjury prevents onset of MODSprevents onset of MODS
The Golden HourThe Golden Hour
What should we be doing?What should we be doing?
Rapid assessmentRapid assessment
Resuscitation and stabilizationResuscitation and stabilization
Definitive management/TransferDefinitive management/Transfer
ATLS
ATLS OverviewATLS Overview
The ATLS ConceptThe ATLS Concept
Primary SurveyPrimary Survey
AdjunctsAdjuncts
Secondary SurveySecondary Survey
Definitive Care/TransferDefinitive Care/Transfer
ATLS OverviewATLS Overview
The ATLS ConceptThe ATLS Concept
treat life threatening injuries as treat life threatening injuries as they are identifiedthey are identified
assessment/diagnosis and assessment/diagnosis and resuscitation are simultaneousresuscitation are simultaneous
ATLS OverviewATLS Overview
Primary SurveyPrimary Survey
AA AirwayAirway BB BreathingBreathing CC CirculationCirculation DD (neurologic) Disability(neurologic) Disability EE Exposure / EnvironmentExposure / Environment
AMPLEAMPLE
ATLS OverviewATLS Overview
AdjunctsAdjuncts
Urinary catheterUrinary catheter NG tubeNG tube XraysXrays
ATLS OverviewATLS Overview
Secondary SurveySecondary Survey
Thorough “head to toe” assessmentThorough “head to toe” assessment
Definitive Care/TransferDefinitive Care/Transfer
Deadly DozenDeadly Dozen
Lethal SixLethal Six airway obstructionairway obstruction tension PTXtension PTX open PTXopen PTX flail chestflail chest massive massive
hemothoraxhemothorax cardiac tamponadecardiac tamponade
Hidden SixHidden Six pulmonary contusionpulmonary contusion diaphragmatic diaphragmatic
tear/rupturetear/rupture tracheobronchial tracheobronchial
injuryinjury blunt cardiac injuryblunt cardiac injury thoracic aortic thoracic aortic
disruptdisrupt esophageal injuryesophageal injury
ATLS SpecificsATLS Specifics
AA - airway - airway ((with C-spine protectionwith C-spine protection))
PreventablePreventable Deaths from Airway Deaths from Airway ProblemsProblems failure to recognize need for airwayfailure to recognize need for airway inability to establish airwayinability to establish airway failure to recognize incorrect placementfailure to recognize incorrect placement displacement of previously placed airwaydisplacement of previously placed airway failure to recognize need for ventilationfailure to recognize need for ventilation aspiration of gastric contentsaspiration of gastric contents
Airway AlgorithmAirway Algorithm
ATLS SpecificsATLS Specifics
AA - airway - airway ((with C-spine protectionwith C-spine protection))
Rapid Sequence Intubation (RSI)Rapid Sequence Intubation (RSI) preoxygenationpreoxygenation cricoid pressurecricoid pressure sedation (etomidate, midazolam)sedation (etomidate, midazolam) succhinylcholinesucchinylcholine orotracheal intubationorotracheal intubation cuff inflation, confirmation of positioncuff inflation, confirmation of position release of cricoid pressurerelease of cricoid pressure
ATLS SpecificsATLS Specifics
Alternative Alternative AAirway Devices/Optionsirway Devices/Options nasotracheal intubationnasotracheal intubation LMA / intubating LMALMA / intubating LMA Glide scopeGlide scope fiberoptic intubationfiberoptic intubation surgical airwaysurgical airway
needleneedle
percutaneouspercutaneousopenopen
ATLS SpecificsATLS Specifics
Alternative Alternative AAirway Devices/Optionsirway Devices/Options
ATLS SpecificsATLS Specifics
Surgical Surgical AAirwayirway
ATLS SpecificsATLS Specifics
AA - airway ( - airway (with C-spine protectionwith C-spine protection))
ATLS: ATLS: lateral C spine filmlateral C spine film complete C spine series during secondary complete C spine series during secondary
surveysurvey
Current practice: Current practice: in ER assume C spine injuryin ER assume C spine injury no C spine films in ERno C spine films in ER CT scan of C spine with reconstructionsCT scan of C spine with reconstructions
ATLS SpecificsATLS Specifics
AA - airway ( - airway (with C-spine with C-spine protectionprotection))
““Clearing” the C spine Clearing” the C spine (multiple trauma (multiple trauma patient)patient) rarely done in ER (except fully conscious, no rarely done in ER (except fully conscious, no
distracting injury)distracting injury) CT scan with reconstructionsCT scan with reconstructions Further studiesFurther studies
MRIMRI Flexion - Extension viewsFlexion - Extension views
ATLS SpecificsATLS Specifics
BB – breathing – breathing oxygenationoxygenation ventilationventilation monitoringmonitoring
clinical (auscultation)clinical (auscultation)
OO22 saturation saturation
EtCOEtCO22
ABG’sABG’s
ATLS SpecificsATLS Specifics
CC - circulation (shock management) - circulation (shock management)
recognition and resuscitation from recognition and resuscitation from shockshock
post traumatic shock is hemorrhagic post traumatic shock is hemorrhagic shock shock until proven otherwiseuntil proven otherwise
Shock
Obstructive
Tension pneumo
Nonobstructive
Cardiac tamponade
Distributive Nondistributive
Sepsis/SIRS
Anaphylaxis
Neurogenic
Hypovolemic
Cardiogenic
Hemorrhagic
Third spacing
ATLS SpecificsATLS Specifics
CC - circulation (shock management) - circulation (shock management)
Classification and mechanisms of shockClassification and mechanisms of shock obstructiveobstructive
tension pneumothoraxtension pneumothorax cardiac tamponadecardiac tamponade
Tension pneumothorax is the most EASILY corrected cause of shock
ATLS SpecificsATLS Specifics
CC - circulation (shock management) - circulation (shock management)
Classification and mechanisms of shockClassification and mechanisms of shock distributivedistributive
spinal cord injuryspinal cord injury sepsissepsis anaphylaxisanaphylaxis
ATLS SpecificsATLS Specifics
CC - circulation (shock management) - circulation (shock management)
Classification and mechanisms of shockClassification and mechanisms of shock cardiogeniccardiogenic
myocardial contusionmyocardial contusion valvular disruptionvalvular disruption ischemic injuryischemic injury
ATLS SpecificsATLS Specifics
CC - circulation (shock management) - circulation (shock management)
Classification and mechanisms of shockClassification and mechanisms of shock hypovolemichypovolemic
blood lossblood loss fluid lossfluid loss
ATLS SpecificsATLS Specifics
CC - circulation (shock management) - circulation (shock management)
ACS Classes of Hemorrhage ACS Classes of Hemorrhage classes I - IVclasses I - IV based on estimated blood loss and effect based on estimated blood loss and effect
on vital signson vital signs
ATLS SpecificsATLS Specifics
C – C – circulation (shock circulation (shock management)management)
STOP STOP the BLEEDINGthe BLEEDING External blood lossExternal blood loss Internal blood lossInternal blood loss
REPLACEREPLACE blood loss blood loss
ATLS SpecificsATLS Specifics
C – C – circulation (shock management)circulation (shock management)
Vascular accessVascular access
Direct pressureDirect pressure
Fluid administrationFluid administration
Assessment of responseAssessment of response
ATLS SpecificsATLS Specifics
C – C – circulation (shock management)circulation (shock management)
Fluid AdministrationFluid Administration
ATLS: initial 2 litre bolus of ATLS: initial 2 litre bolus of warmedwarmed Ringer’s (NS)Ringer’s (NS)
ATLS SpecificsATLS Specifics
C – C – circulation (shock circulation (shock management)management)
CrystalloidCrystalloid IsotonicIsotonic HypertonicHypertonic
ColloidColloid AlbuminAlbumin Starch (Pentaspan, Voluven)Starch (Pentaspan, Voluven)
ATLS SpecificsATLS SpecificsFluid Administration - which fluid?Fluid Administration - which fluid?
CrystalloidCrystalloid massive fluid administrationmassive fluid administration diffuse edema (?worsens cerebral edema)diffuse edema (?worsens cerebral edema) ?contributes to “compartment syndrome”?contributes to “compartment syndrome”
ColloidColloid no demonstrated benefit (?harm, SAFE trial)no demonstrated benefit (?harm, SAFE trial) costliercostlier
Hypertonic saline (3%, 7.5% =/- dextran)Hypertonic saline (3%, 7.5% =/- dextran) no demonstrated benefit (trial in progress)no demonstrated benefit (trial in progress) hypernatremiahypernatremia
ATLS SpecificsATLS Specifics
C – C – circulation (shock circulation (shock management)management)
Blood replacementBlood replacement type Otype O type specifictype specific fully crossmatchedfully crossmatched
ATLS SpecificsATLS Specifics
CC - circulation (shock management) - circulation (shock management)
Role of Factor VIIaRole of Factor VIIa initially used for hemophiliainitially used for hemophilia initiates thrombin formation by binding with initiates thrombin formation by binding with
exposed tissue factorexposed tissue factor reverses coagulopathyreverses coagulopathy use after use after
surgically accessible surgically accessible bleeding controlled bleeding controlled
coag factors and plateletscoag factors and platelets
ATLS SpecificsATLS Specifics
CC - circulation (shock management) - circulation (shock management)
Role of Factor VIIaRole of Factor VIIa parallel RCT’s in blunt/pen trauma parallel RCT’s in blunt/pen trauma
((JTrauma 05JTrauma 05) decreased RBC use in ) decreased RBC use in blunt trauma better outcome blunt trauma better outcome in coagulopathic patients (CCM 06) in coagulopathic patients (CCM 06)
better outcome in TBI (better outcome in TBI (NEJM 05NEJM 05)) multiple case reports/series showing multiple case reports/series showing
benefit in reversal of coagulopathy benefit in reversal of coagulopathy and lower transfusionand lower transfusion
ATLS SpecificsATLS Specifics
C – C – circulation (shock circulation (shock management)management)
Stop InternalInternal Bleedingchest, abdomen, pelvis
ATLS SpecificsATLS Specifics
Recognition of thoracic Recognition of thoracic hemorrhagehemorrhage clinicalclinical
CXRCXR
Chest tube(s)Chest tube(s)
ATLS SpecificsATLS Specifics
Recognition of abdominal Recognition of abdominal hemorrhagehemorrhage clinicalclinical FASTFAST DPLDPL laparotomylaparotomy
ATLS SpecificsATLS Specifics
Recognition of pelvic hemorrhageRecognition of pelvic hemorrhage clinicalclinical
pelvic x-raypelvic x-ray
CT scanCT scan
Damage Control LaparotomyDamage Control Laparotomy
Part 1Part 1 stop all overt arterial bleedingstop all overt arterial bleeding pack other bleeding pack other bleeding control contaminationcontrol contamination modified closuremodified closure
Damage Control LaparotomyDamage Control Laparotomy
Part 2Part 2 return to ICU for warming, return to ICU for warming,
correction of coagulation and correction of coagulation and acidosisacidosis
Part 3Part 3 return to OR for definitive closurereturn to OR for definitive closure
ATLS SpecificsATLS SpecificsDD – (neurologic) Disability – (neurologic) Disability
ATLS: rapid recognition of lateralizing ATLS: rapid recognition of lateralizing injury (potentially surgically injury (potentially surgically correctable)correctable)
confirmation by CT scanconfirmation by CT scan emergency craniotomy for drainageemergency craniotomy for drainage
ATLS SpecificsATLS Specifics
EE - exposure / environment - exposure / environment remove clothingremove clothing keep covered between examinations keep covered between examinations
(hypothermia)(hypothermia) logrolllogroll full examination of extremitiesfull examination of extremities
ThanksThanks
QQ –questions? –questions?