Major Trauma Management and Trauma Team Roles

Dr Christopher MoseleyCME Teaching 8th September 2016

Objectives

• Definition• State Trauma Network• Trauma Calls• Team Roles• Trauma mindset• Major Hemorrhage Protocol

Trauma Definition• A term derived from the Greek for “WOUND”

• It refers to bodily injury.

• It defined as tissue injury due to direct effects of externally applied energy. Energy may be mechanical, thermal, electrical, electromagnetic or nuclear.

• Includes: burns, drowning, smoke, inhalation and fall.

• Excludes: poisoning/toxic ingestion.

Trauma Definition

Major trauma — ‘multiple trauma’ — refers to major injury affecting more than one body system. It can also be defined as an Injury Severity score > 15.

Trauma in AustraliaTrauma accounts for: • 7.5% of total deaths

• 5.5% of hospitalisations

• 7% of the total burden of disease in Australia

* (Australian Institute of Health and Welfare, 2008).

WA Trauma Network

WA Trauma NetworkTrauma at Charles

Trauma at Charles

WA Trauma NetworkTRIMODAL DISTRIBUTION OF

TRAUMA DEATHS.First Peak – Seconds to minutes (50% all

deaths)

Second Peak – Minutes to hours. This is why we do what we do as this is where we save lives

Third Peak – Days to weeks

Major Trauma Code 10 minutes

What now?

Preparation, triage and activation of the trauma resuscitation team

Recognize your in it!

PEOPLE

PLACE

EQUIPMENT AND DRUGS

People1) Clear roles and organization

2) Effective communication

3) Support from other hospital areas, transfer services and trauma centres

WA Trauma Network

Trauma Definition• A term derived from the Greek for “WOUND”

• It refers to any bodily injury.

• It defined as tissue injury due to direct effects of externally applied energy. Energy may be mechanical, thermal, electrical, electromagnetic or nuclear.

• Included:burns, drowning, smoke, inhalation and fall.

• Excluded: poisoning/toxic ingestion.

Drugs and EquipmentConsider what may be required prior to arrival:• Difficult airway trolley• Blood including rapid transfuser• Drugs – e.g analgesia, TXA• IO kit• Procedure kits – chest tubes/thoracotomy kit

*USS machine in the bay ready to go

SpecialtiesSpecialties may include orthopedics, neurosurgery, cardiothoracics, plastics, ENT and ophthalmology.

Early notification of operating theatre staff and ICU is also crucial for critically ill trauma patients.

Radiography and radiology staff are a key part of trauma team activation.

https://i.ytimg.com/vi/TQLtISfDxcc/maxresdefault.jpg

http://emcrit.org/wee/real-surgical-airway/

HAEMOSTATIC RESUSITATION

In the bleeding trauma patient if it doesn’t carry oxygen or it doesn’t clot

then use with caution

1 in 4 trauma patients bleed abnormallyThe phenomenon of an early coagulopathy in trauma – which goes by many names, including the Acute Coagulopathy of Trauma-Shock (ACoTS) – can occur soon after injury, and is physiologically distinct from the DIC-like phenomenon associated with the “lethal triad”

Trauma patients bleed abnormally

Hypothermia Decreases platelet responsiveness, increases platelet sequestration in liver and spleen, reduces Factor function eg Factors XI and XII. Alters fibrinolysisAcidosis pH strongly effects activity of Factors V, VIIa and X. Acidosis inhibits thrombin generation. Cardiovascular effects of acidosis (pH <7.2) – decreased contractility and CO, vasodilatation and hypotension, bradycardia and increased dysrhythmias

Lethal Triad

Early hyperfibrinolysis

• Give blood products instead of isotonic crystalloid fluid aiming for limited volume replacement.

• Large volume crystalloids can lead to dilutional coagulopathy and exacerbate bleeding.

• Crystalloids have no O2 carrying capacity and do little to correct the anaerobic metabolism and O2 debt associated with shock.

• Oedema, compartment syndrome, resp distress

Blood Vs Crystalloid

Provides resuscitation with blood components resembling whole blood with the aims of:

• maintain circulating volume• limit ongoing bleeding• prevent the lethal trial of hypothermia, acidosis and

acute coagulopathy of traumaTypical triggers are:• expected or actual haemorrhagic shock• 4 PRBCs administered and instability persists

Haemostatic Resusitation

• Involves blood component ratios of 1 or 2 RBCs : 1 FFP : 1 platelets

• Rick Dutton freely admits that he made up the ratio of 1:1:1 based in the rationale that it mimics the composition of whole blood

• Australian National Guidelines advocates 2:1:1 ratio

HOW?

• There is no RCT evidence for RBC:FFP:platelet ratios of 1-2:1:1 versus other ratios/ fluids

• The PROPPR trial (2015) found no statistically significant mortality difference on the primary outcome of mortality between massive transfusion protocols based on 1:1:1 and 2:1:1 ratios. There was an absolute difference in mortality of about 4% favouring the 1:1:1 ratio

Evidence

• Other agents may be given based on blood tests:• INR >1.5 – FFP• Hb <100 in an actively bleeding -> PRBCs• Calcium <0.8 - calclium gluconate• Platelets <80 - platelets• platelet dysfunction (e.g. drugs) - platelets

Adjuncts

Tranexamic AcidTranexamic acid (TXA) is an anti-fibrinolytic agent that can/should be used early in the resuscitation of bleeding trauma patients

The effect of TXA on mortality in bleeding trauma patients is very time-dependent, conferring a huge survival advantage if given early

Tranexaminc AcidTranexamic acid (TXA) use is supported by the CRASH2 trial:

• a multicenter international RCT• Mortality benefit if given to major trauma patients

within 3 hours of injury.

Cryoprecipitate• Fibrinogen is the primary substrate for clot

formation (along with platelets)• There is a consistent link between falling fibrinogen

and mortality in trauma• The key is to measure and follow serum fibrinogen in

bleeding patients – a fibrinogen less than 1.0 g/L identifies a hypofibrinogenemic state, the antidote for which is cryoprecipitate.

Management of Major Trauma, Team roles

…and stuff…

This Is the sum total of my knowledge on the subject so

questions to the boss!