the golden hour of trauma past, present and future€¦ · damage control surgery • rapid initial...
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The Golden Hour of Trauma Care: past, present and future
Gill Cryer MD
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Man kicked by horse
• Complains of severe abdominal pain• Horse shoe mark RUQ• Taken to nearest hospital• Evaluated by:
– Triage nurse?– Family doctor?– EM physician?
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Man kicked by horse• Suspect internal bleeding
• General surgeon called
• Surgeon arrives 2 hours later
• Takes patient to operation
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Man kicked by horse
• Lots of bleeding– ran out of blood
• Surgeon not used to operating on liver
• No help• Patient died!
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Trimodal distribution of death from Trauma
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Immediately life threatening injuries
• Brain injury (50% of mortality)• Bleeding/shock (35% of mortality)• May have both• Both are time sensitive, minutes count!
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The Golden Hour• The goal is to find immediately life threatening injuries and fix them.
• Trauma center high performance team always ready and waiting for the patient when they arrive
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Trauma CenterCommitment
• ALL departments– Trauma Surgeon – Other physicians
• Emergency medicine• Critical care• Neurosurgery• Orthopedics• Cardiothoracic• Plastics and ENT• Anesthesia • Radiology
– Nurses– Every other staff member
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Trauma Center
• Open 24/7• All resources available
– Operating rooms– CT scan– Physician specialists
• They know you are coming
• The team is waiting for you ready to go!
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Standards for Care of the Injured Patient
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ACS COT prioritization strategy
• Airway• Breathing• Circulation
– Free bleeding–Contained bleeding
• Disability– Space occupying lesion–prevent secondary injury
ATLS course
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Initial strategy• Rapid resuscitation
–Blood not crystalloid–Restore perfusion–Buy time to use diagnostic tools
• Find the problem– Site of hemorrhage–Brain injury
• Fix the problem
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Trauma induced coagulopathy
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Blood clot
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Plasma
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Packed red blood cells
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Platelets
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65%
34%
20%
0
10
20
30
40
50
60
70
0:22 - 1:4 1:3.9 - 1:2.1 1:2 - 1:0.59
Mortality %
Chi SquareRB: p=0.006RG: p<0.001BG: p=0.034
Effect of FFP:RBC Ratio on Overall Mortality
n=31 n=56 n=165
FFP:RBC Ratio
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Damage control resuscitation
• Whole blood or 1:1:1 ratio PRBC, FFP and platelets
• Minimize crystalloid• Arrest bleeding and contamination • Restore perfusion• Restore normal physiology• Delayed or staged definitive repair
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Damage control surgery• Rapid initial control of hemorrhage and contamination and temporary closure
• ICU for physiologic resuscitation • Reoperation for planned definitive repair once normal physiology has been restored.
• Avoid the lethal triad of hypothermia, acidosis and coagulopathy (bloody vicious cycle)
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Golden hour of hemorrhagic shock
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Diagnostic tools: bed side ultrasound
Blood in the abdomen! She needs an operation!
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Definitive diagnostic test: CAT SCAN
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What operations/procedures are needed?
Therapeutic lap 24% Craniotomy 6%
Therapeutic angio 20%
Thoracotomy 5%
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Operating room (60%)
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Extremity damage control• GSW upper arm, no pulse at wrist • Expedited exploration
–Humerus fx, transected brachial artery and nerve
–Hemostastis, Javid shunt, external fixator, forearm fasciotomy
–Pulse restored–Stabilize for later definitive care
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Damage control: 1st operation hemostasis, shunt, fasciotomy and external fixator
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Damage control: first stage completed
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2nd operation: definitive repair artery, tagged median nerve
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Adjusted fixator and VAC
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Interventional Radiology (20%)
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Selective Angiography and TrancatheterEmbolization
Pre‐embolization Post‐embolization
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Endovascular stent of subclavian artery injury
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Stenting the transected aortaZager et al. J Trauma, 2003
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Surgical ICU (25%)
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Epidural Hematoma
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Case presentation• 25 yo woman is severely injured in a
motor vehicle crash
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Case presentation• In ED BP 90/40, pulse130, pale• Right femur deformity• Pelvic tenderness
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Case presentation• Blood pressure improves with resuscitation with PRBC, Plasma and Platelets
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Pelvic fracture on X-ray
Vertical shear fracture
Angio is called immediately on seeing this X‐ray
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Ct-scan shows pelvic arterial bleeding
Angiographer there to see scan and team is setting up
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In angio within 30 minutes
Blood pressure stabilized immediately after embolizationCT‐scan negative for any other injuries
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Patient stable for damage control operation on femur fracture and pelvic fracture
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3 days later definitive open reduction and internal fixation
Back to work 6 weeks later and normal function at 6 months
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Angiography Disadvantages
• 32 unstable patients with negative FAST went from ED to Angio
• 47% had therapeutic angio
• 41% required therapeutic laparotomy
• Some patients were in the wrong place
• Time consuming
What if the problem is in the belly, chest, or head?
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So put it all together
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Hybrid operating room• C‐arms• CT‐ scan on rails• MRI portable• Robotics• 3D‐imaging• Fusion imaging• Overlay imaging
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Needs a lot of room (70 sq meters)
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Control Room, lead shielding
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Lots of people (8-20): 24/7
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Logistical problems for trauma
• Very expensive, who pays?• Who uses it?• Will it be available?• Staffing 24 hours per day• Speed of information transfer?• Lots that can go wrong• Coordination of multiple teams
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ED thoracotomy to the OR
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Ongoing blood product resuscitation
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Trauma team in the abdomen
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Angio and Ortho setting up
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Angio in the OR
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Ex fix going on
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Trauma, ortho and angio
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Multifunctional trauma OR: the future?
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Summary of the “golden hour”
• Severely injured patient to trauma center• Damage control resuscitation• Injuries identified • Damage control surgery• Stabilization in the ICU• In the future do it all in the same place
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Don’t let the golden hour sneak up on you!
Thank you
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Next to the operating room
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Advances: Skill and Technology
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