dr matt wiles sheffield teaching hospitals nhs trust … · 2014. 3. 13. · manual in-line...
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Dr Matt Wiles Sheffield Teaching Hospitals NHS Trust
@STHJournalClub http://sthjournalclub.wordpress.com
To examine the evidence basis for Advance Trauma Life Support (ATLS) management, in particular:
RSI & Cricoid Pressure
Manual in-line stabilisation
BP management
Management of TBI
The investigate the impact of ATLS training on trauma related morbidity & mortality
[To consider the most effective way of training in trauma management]
"When I can provide better care in the field with limited resources than my children and I received at the primary facility, there is something wrong with the system and the system has to be changed.“
James K. Styner
All trauma patients will require a rapid sequence induction Opiates are contraindicated during a RSI in a trauma patient Ketamine is contraindicated in traumatic brain injury Manual in-line stabilisation should be instituted during tracheal
intubation of the unconscious trauma patient PEEP increases ICP in patients with TBI Permissive hypotension decreases bleeding in blunt trauma and
prevents clot rupture A trauma patient with a GCS ≤ 8 requires tracheal intubation ATLS protocols have reduced mortality from major trauma Nasopharyngeal airways are contraindicated in suspected TBI In TBI and raised ICP, ETCO2 should be maintained at 4.5.5.0 kPa A haemodynamically unstable trauma patient should never have a
whole body trauma CT
“So let it be written, so let it be done..”
“False principles or rules handed down through generations of medical providers and accepted without serious challenge or investigation”
Dr Chris Nickson (@precordialthump)
Rapid Sequence Induction
[Can J Anesth 2007; 54: 748-764]
Permissive hypotension
[Anaes 2013; 68: 445-452]
Manual in-line stabilisation
[Br J Anaesth 2000; 84: 705-709]
Trauma nasopharyngeal airways
[Emerg Med J 2005; 22: 394-396]
GCS as a trigger for intubation
[Trauma 2003; 54: 671-680]
[Emerg Med J 2007; 24: 139-141]
Guly et al. Resuscitation 2011; 82: 556-559
Mutschler et al. Resuscitation 2013; 84: 309-313
Demetriades et al. J Am Coll Surgeons 2005; 201: 343-348
De Knegt et al. Injury 2008; 39: 993-1000
“Rules are for the obedience of fools and the guidance of wise men”
Douglas Bader
Sequential assessment Permissive hypotension Haemostatic resuscitation Etomidate Importance of CT
Sellick (1961) n=26, in head down position Force of >44 N only effective in 50% BVM ventilation difficult in 50% Distorted view at laryngoscopy in 40% Only effective for 2-4 min (if at all!) No evidence that CP improves outcome BUT....
Origin uncertain – ATLS guidance 1984 Data from cadaveric studies, healthy
volunteers and case series (n=96) Direct laryngoscopy/intubation cause less
cervical movement than a jaw thrust Several studies suggest MILS has no effect
on cervical segment movement
Method Grade 1 Grade II Grade III
Optimal positioning 129 26 2
MILS 75 48 34
Due to prolonged deformation and/or hypotension
Hyperflexion worse than hyperextension
Both are unlikely during DL AFOI may not be safer
Several claims in US Closed Claims Database
5% patients with SCI will deteriorate
Early (24 h)
Later (1-7 days)
Late (weeks [post-traumatic ascending myelopathy])
Hypoxia associated with worse outcome Marked hypo- and hypercapnia similarly bad
Must calibrate PaCO2 with ETCO2
-2
-1
0
1
2
3
4
2 3 4 5 6 7
Pa
CO
2-E
TC
O2
Mean CO2 (PaCO2+ETCO2/2)
Hypoxia associated with worse outcome Marked hypo- and hypercapnia simliarly bad What about PEEP?
A single episode of hypotension doubles mortality
.
Year n Median age (years)
% aged > 50 years
Traumatic Coma Data Bank 1984-1987 746 25 15
UK Four Centre Study 1986-1988 988 29 27
EBIC Core Data Survey 1995 1005 38 33
Rotterdam Cohort Study 1999-2003 774 42 39
Austrian Severe TBI Study 1999-2004 492 48 (mean) 45
TARN Review 2003-2009 15173 39 (mean) Unknown
Italian TBI Study 2012 1366 45 44
68 63
54 56
39
19 13
0
10
20
30
40
50
60
70
80
19-29 30-39 40-49 50-59 60-69 70-79 > 80
Series 1
A single episode of hypotension doubles mortality
Head injury alone rarely causes hypotension Treatment of cardiovascular instability takes
precedence over direct head injury intervention No evidence for any one vasopressor Trials with permissive hypotension excluded
those with TBI
Retrospective analysis 15 733 patients with TBI following blunt trauma
Prospective work from TARN dataset 3444 patients with penetrating trauma
Prospective work from TARN dataset 47 927 patients with blunt trauma
Ketamine increases ICP/CBF in spontaneously breathing volunteers (III)
No effect on ICP with controlled ventilation and sedation (III)
Greater CPP maintained with ketamine and lower vasopressor requirements (II)
No effect on cerebral autoregulation (III)
Advanced Trauma Life Support program increases emergency room application of trauma resuscitative procedures in a developing country. Ali et al. Trauma 1994; 36: 391-394
Trauma outcome improves following the Advanced Trauma Life Support Program in a developing country. Ali et al. Trauma 1993; 34: 890-899
Clinical Impact of Advanced Trauma Life Support. Van Olden et al. Am J Emerg Med 2004; 22: 522-525
“Everything is awesome. Everything is cool when you’re part of a team”
President Business
[Trauma Team Performance. Barach & Weimger; http://www.academia.edu/5270549/ITTACS_Team_Performance]
[Capella et al. J Surg 2010; 67: 439-443]
[Capella et al. J Surg 2010; 67: 439-443]
All trauma patients will require a rapid sequence induction Opiates are contraindicated during a RSI in a trauma patient Ketamine is contraindicated in traumatic brain injury Manual in-line stabilisation should be instituted during tracheal
intubation of the unconscious trauma patient PEEP increases ICP in patients with TBI Permissive hypotension decreases bleeding in blunt trauma and
prevents clot rupture A trauma patient with a GCS ≤ 8 requires tracheal intubation ATLS protocols represents the gold standard of trauma care Nasopharyngeal airways are contraindicated in suspected TBI In TBI and raised ICP, ETCO2 should be maintained at 4.5.5.0 kPa A haemodynamically unstable trauma patient should never have a
whole body trauma CT