polytrauma shock - semmelweis egyetem€¦ · polytrauma iss > 20 and chest trauma ais > 2 !...
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POLYTRAUMA SHOCK
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• TRAUMA RELATED COSTS IN THE U.S. 400 BILLION $ • 3.8 MILLION DEATHS PER YEAR • THE LEADING CAUSE OF DEATH IN PERSONS AGED
1 TO 45 IN THE MOST DEVELOPED COUNTRIES • TRIMODAL DEATH DISTRIBUTION
1. SECONDS, MINS FOLLOWING INJURY DUE TO BRAIN, C. SPINE, LARGE VESSEL INJ.
2. 1-2 HOURS FOLLOWING INJURY DUE TO EPIDURAL HAEMATOMAS, BLEEDINGS
GOLDEN HOUR 3. SEVERAL DAYS FOLLOWING INJURY DUE TO M.O.F., SEPSIS
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TRIMODAL DEATH DISTRIBUTION 50% 40% 30% 20% 10% 0%
HOURS 0 1 2 3 4 WEEKS 1 2 3 4
TRIMODAL BIMODAL? THE SECOND GROUP IS DECREASING DUE TO PROPER TREATMENT
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GOLDEN HOUR NOT ONLY SALVAGEABILITY BUT MANY LATE PROBLEMS (SIRS, MOF) ARE THE CONSEQUENCES OF THE PRIMARY HYPOXIA AND MEDIATOR RELEASE
SILVER DAY BRONZE WEEK PLATINA 10 MIN
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DEFINITION OF POLYTRAUMA A. INJURY TO ONE OR MORE BODY REGIONS OR
ORGANS OF WHICH ONE, OR THEIR COMBINATIONS IS LIFE THREATENING
B. INJURY TO MORE BODY REGIONS FOLLOWING
WHICH, DURING TREATMENT, WE HAVE TO MAKE COMPROMISES
C. INJURY TO HOLLOW ORGANS + INJURY TO
EXTREMITIES
D. INJURY DEFINED BY A SCORING SYSTEM
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TRAUMA SCORE NUMBER OF BREATHS PER MIN 0-4 INTENSITY OF BREATHING 0-1 SYSTOLIC BLOOD PRESSURE 0-4 CAPILLARY REFILL 0-2 GLASGOW COMA SCALE 0-5 POSSIBILITY FOR SURVIVAL 16+ <2
99% 0%
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GLASGOW COMA SCALE EYE OPENING SPONTANEOUS 4
TO SPEECH 3 TO PAIN 2 NONE 1
BEST MOTOR RESPONSE OBEYS COMMANDS 6
LOCALIZES PAIN 5 NORMAL FLEXION 4 ABNORMAL FLEXION 3 EXTENSION 2 NONE 1
VERBAL RESPONSE ORIENTED 5
CONFUSED CONVERS. 4 WORDS 3 SOUNDS 2 NOTHING 1
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ABBREVIATED INJURY SCALE (ISS)
1 MILD 2 MEDIUM 3 SEVERE 4 VERY SEVERE 5 CRITICAL 6 NOT SURVIVABLE
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INJURY SEVERITY SCORE (ISS) SIX REGIONS THE THREE MOST SEVERE THE SQUARE OF EACH VALUE THE SUM OF THE RESULTS • HEAD AND NECK • FACE • CHEST • ABDOMEN • EXTREMITIES (PELVIS) • SKIN
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EXAMPLE VALUE VALUE² HEAD, NECK BRAIN CONTUSION 3 9
FACE NONE 0 CHEST UNSTABLE CHEST 4 16 ABDOMEN SPLEEN RUPTURE 2
SEVERE LIVER RUPTURE 5 25
EXTREMITIES FRACTURE OF THE FEMUR 3
SKIN BRUISES 1
SUM 50 SEVERE: MORE THAN 20
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PROBLEMS OF ISS
• IN ONE BODY REGION ONLY ONE INJURY • SOMETIMES CAN BE DEFINED AFTER SURGERY • ONLY 3 REGIONS • THE 2ND MOST SEVERE IN ONE REGION CAN BE
WORSE THAN THE MOST SEVERE IN AN OTHER REGION
• PHYSIOLOGY DATA NOT TAKEN INTO CONS. • EVERY REGION WITH THE SAME IMPORTANCE?
NISS (NEW ISS)
THE 3 MOST SEVERE INJURY
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TREATMENT 1. PREHOSPITAL STAGE
AIRWAY/BREATHING CONTROL OF EXTERNAL BLEEDING AND SHOCK IMMOBILISATION/DRUG THERAPY TRANSFER TO THE CLOSEST TRAUMA CENTER
2. IN- HOSPITAL STAGE THE SAME AS 1, BUT PROPER EQUIPMENT/STAFF (TRAUMA SURGEON)
TRIAGE SORTING OF THE PATIENTS MULTIPLE CASUALTIES / MASS CASUALTIES
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PLAY AND STAY GERMANY: TRAINED DOCTORS INFUSIONS, TREATMENT
SCOOP AND RUN U.S.: PARAMEDICS, BASIC SUPPORT, FAST TRANSFER
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ATLS CONCEPTION ADVANCED TRAUMA LIFE SUPPORT ABCDE APPROACH FIRST THE LIFE THREATENING INJURY THE IMMEDIATE EXACT DIAGNOSIS IS NOT
IMPORTANT THE TIME FACTOR IS THE MOST IMPORTANT DO NOT DO MORE HARM EMS, BLS, ALS
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TIME TO BEAT
AIRWAY 1-5 MINS BREATHING/HYPOXIA 5-10 MINS CIRCULATION/BLEEDING 10-30 MINS DISABILITY/BRAIN STEM HERNIATION 30-60 MINS
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ATLS CONCEPTION PRIMARY SURVEY A AIRWAY + C SPINE B BREATHING/ VENTILATION/
OXYGENISATION C CIRCULATION - STOP THE BLEEDING
RESTORE VOLUME D DISABILITY /NEUROL STATUS
E EXPOSE/ ENVIRONMENT/ BODY TEMP.
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LOGROLL BODY 3 PERS. . / HEAD + 1
HANDS OVERLAP
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FAST EXAMINATION 10 SECONDS RESUSCITATION PRIMARY SURVEY 1 MINUTE (A, B, C, D, E) SECONDARY SURVEY FOCUSED EXAMINATION
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A , B AIRWAY/BREATHING (OXYGENISATION)
ADEQUATE AIRWAY ADEQUATE OXYGENISATION „DEFINITIVE AIRWAY”
(TUBE WITH INFLATED CUFFAL IN THE TRACHEA)
TO MAINTAIN THE ADEQUATE OXYGENISATION
AGAIN AND AGAIN GCS < 9
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A, B AIRWAY/BREATHING (OXYGENISATION)
C SPINE PROTECTION PHYSICAL EXAMINATION (TENSION PTX) PULSE-OXYMETER (CHEST RTG) SURGICAL AIRWAY AGAIN AND AGAIN
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B BREATHING, OXYGENISATION PROBLEMS IS IT A PROBLEM OF THE AIRWAY OR
VENTILLATION? PTX, TENSION PTX:
NEEDLE THRORACOSTOMY IATROGENIC PTX
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MAIN INJURIES CAUSING A, B PROBLEMS � PTX, TENSION PTX � MASSIVE HTX � FLAIL CHEST � OPEN WOUNDS � MEDIASTINAL WOUNDS � TRACHEAL INJURIES � DIAPHRAGMATIC RUPTURE � PULMONARY CONTUSION
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TENSION PNEUMOTHORAX
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TENSION PTX NEEDLE THORACOCENTESIS
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C CIRCULATION-STOP THE BLEEDING WHAT IS THE SHOCK?
(TISSUE HYPOPERFUSION) TO RECOGNIZE THE SHOCK TO RECOGNIZE THE REASON TREATMENT (VENOUS LINE) THE IMPORTANCE OF EARLY RECOGNITION TO EVALUATE PATIENT RESPONSE
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SHOCK INADEQUATE TISSUE PERFUSION AND OXYGENISATION DOES NOT RESULT FROM ISOLATED BRAIN INJURY HAEMORRHAGE IS THE MOST COMMON CAUSE VASOPRESSORS ARE CONTRAINDICATED ANY INJURED PATIENT WHO IS COLD AND TACHYCARDIC IS CONSIDERED TO BE IN SHOCK
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THE CAUSE OF SHOCK BLEEDING NON BLEEDING BLEEDING TENSION PTX (FAST) CARDIAC TAMP. FOCUSED CARDIOGENIC ASSESSMENT NEUROGENIC SONOGRAPHY in SEPTIC TRAUMA CHEST, PELVIS X-RAY
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MAIN CAUSES FOR BLOOD LOSS � LARGE VESSEL INJURIES � MASSIVE HAMOTHORAX � INTRAABDOMINAL INJURIES � PELVIC FRACTURES � MULTIPLE FRACTURES
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TREATMENT FLUID THERAPY, BLOOD THERAPY COMPRESSION BANDAGE
CLOSE THE PELVIS SURGERY –
THORACOTOMY, LAPAROTOMY
PATIENT RESPONSE AGAIN AND AGAIN
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FLUID REPLACEMENT 2 LITER WARM LACTETED RINGER
20 ML/ KG IN CHILDREN 3:1 RULE MIN 16 GAUGE PERIPHERIAL NEEDLE CENTRAL VEIN(S)
SUBCLAVIAN, JUGULAR, FEMORAL. INTRAOSSEOUS
HYPEROSMOL. RINGER?
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PATIENT RESPONSE „RAPID RESPONDER”
CRISTALLOIDS „TRANSIENT RESPONDER”
CRISTALLOIDS, TRANSFUSION PATIENT RESPONSE?
„NON-RESPONDER” CRISTALLOID, IMMEDIATE TRANSFUS. SURGERY
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I. GR. BLOOD LOSS - 15% - 750 ml RESPONDER CRISTALLOID
II. GR. BLOD LOSS 15-30% -1500 ml RESPONDER CRISTALOID, BLOOD
III. GR. BLOOD LOSS 30-40% -2000 ml TRANSIENT/NON RESPONDER CRISTALLOID, BLOOD, SURGERY
IV. GR. BLOOD LOSS 40%- 2000+ ml NON RESPONDER CRISTALLOID, BLOOD, SURGERY
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SMV RESUSCITATION SMALL VOLUME RESUSCITATION PROBLEM:
DURING MASSIVE VOLUME RESUSCITATION THE RISK OF BLEEDING MAY INCREASE
KEEP THE BLOOD PRESSURE ON AN ACCEPTABLE LEVEL (90 Hgmm) BUT : PERFECT OXYGENISATION
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C STOP THE BLEEDING FLUID THERAPY PROBLEMS AGED CHILD SPORTSMEN DRUGS, MEDICAMENTS I.V. LINE PROBLEMS
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D DISABILITY GCS MONROE - KELLY DOCTRINE NEUROGENIC SHOCK
SYMPHATIC TRACT INJURY VASOMOTORIC INSUFF.
SPINAL SHOCK FOLLOWING SPINAL CHORD. INJ.
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MAIN INJURIES CAUSING „D” PROBLEMS � BRAIN CONTUSION � EPIDURAL – SUBDURAL HEMATOMAS � BRAIN EDEMA � HYPOXIA
� INJURIES TO THE SPINE - FRACTURES
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D, E DISABILTY, ENVIRONMENT PROBLEMS GCS AGAIN AND AGAIN PATIENT STATUS IS WORSENING THERE IS NO FULL BODY EXAM. HYPOTHERMIA WRITTEN RECORDS
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PROBLEMS: BLOOD PRESSURE HGB, HTK VALUES AGE HYPOTHERMIA PREGNANCY SPORTSMEN DUGS PACEMAKER
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STABILIZATION FOR TRANSPORT � FREE AIRWAY � SATURATION MIN. 90% � GCS - 9 � RR 90 Hgmm. I CASE OF POLYTRAUMA 90 (80) Hgmm
IS ENOUGH, IN CASE OF CHILDREN (70 + (2x AGE) INTUBATION OF CHILDREN IS DIFFICULT HYPOXIA!,HYPOTENSION
� TREATMENT OF CONVULSIONS, PAIN RELIEF � PHYSICAL STABILIZATION � MANNISOL IN CASE OF IMMINENT BRAIN STEM
DMG � STEROIDS?? � STAY AND PLAY/ SCOOP AND RUN � IN HUNGARY TIME TO HOSPITAL 90 MINS AVG.
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VACUUM MATTRESS -‐ SPINE BOARD
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STIFNECK
PHILADELPHIA
MIAMI
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RÖGZÍTÉS STIFNECK HEAD STABLE BODY STABLE SPINE BOARD
THERE IS NO ABSOLUTELY GOOD METHOD
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TIMING/TEAMS MINS 1 1-5 5-45 AN. VITAL PARAM. INTUBATION ART. CANULE
REANIMATION NARCOSIS,ANALG. BLOOD GAS RESPIRATORY TR. I.V. FLUIDS WARMING BLOOD SAMPL.
SURG. CHEST DRAIN IMMOBILISATION CATHETER
STOP THE BLEEDING EXAMINATION TETANUS PR. ANTIBIOT.
X-RAY U.SONGRAPHY SKULL, C.SPIN/CT
CHEST, CHEST, ABD. CT PELVIS X-RAY EXTR. X-RAY PYELOGR.
OTHER SPECIALISTS NEUROSURGEON INTERNAL MED. UROLOGY
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DIAGNOSIS
X-‐RAY SKULL C.SPINE CHEST PELVIS
(SPINE) FAST (ULTRASONOGRAPHY)
CT SCAN (BRAIN, ABDOMEN ETC)
FAST SPIRAL CT SPECIFIC X RAYS
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SECONDARY SURVEY ONLY IF THE PATIENT IS STABLE PHYSICAL EXAM. „HEAD TO TOE” „TUBE AND FINGER IN EVERY ORIFICE” FULL NEUROL. STATUS BLOOD SAMPLES, URIN. CATHETER, X-RAYS AGAIN AND AGAIN
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SECONDARY SURVEY AMPLE A ALLERGIES M MEDICATIONS P PAST ILLNESSES L LAST MEAL E EVENTS/ENVIRONMENT WRITTEN RECORDS
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THERAPEUTIC WINDOWS 1. FIRST 24 (48) HOURS 2. 5-7 DAYS FOLLOWING INJURY 3. 2-3 WEEKS
ABDIMINAL ,THORACIC, BRAIN INJURIES EXTREMITIES
VESSEL, NERVE INJURIES INTRAMEDULLARY STABILISATION EXTERNAL FIXATEUR
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THERAPEUTIC WINDOWS I. 24- 48 HOURS II. 5-10 DAYS III. 2-3 WEEKS REACTION INFLAMMATION REGENERATION
SKIN TENDON NERVE BONE
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WHAT, WHEN?
A – AIRWAY AIRWAY INJURY B – BREATHING AIRWAY INJURY, THORACIC INJ. C – CIRCULATION – STOP THE BLEEDING
THORACIC, ABDOMINAL INJ. PELVIC INJ, LARGE VESSEL INJ
D – DISABILITY CNS. INJ
MAXILLOFACIAL, EYE INJ UNSTABLE. SPINE INJ NEURVE INJ. (?)
E – EXTREMITY(?) OPEN FR.
LONG TUBULAR BONE INTRAART. INJ. TENDON INJ. (?) EPIPHYSEAL FR. SOFT TISSUE INJ. /COMPARTEMENTE SY.
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DAMAGE CONTROL SURGERY
EARLY YEARS: DELAYED FRATURE TREATMENT BAD RESULTS NO SKILLED PERSONEL, ANAESTHESIA, FEW HOSPITALS
AROUND 1980: EARLY TOTAL CARE
SOMETIMES GOOD RESULTS BUT MANY FAILURES SIRS, MOF
FROM 2000: DAMAGE CONTROL SURGERY
UNDERSTANDING THE BIOLOGICAL MECHANISMS MEDIATORS
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DAMAGE CONTROL SURGERY DEGREE ON INJURY DEPENDS:
„FIRST HIT”, BIOLOGIC ANSWER, „SECOND HIT” � UNSTABLE STATUS, REANIMATION � COAGULOPATHY THROMBOCYTES < 90.000 � SHOCK, MORE THAN 25 U BLOOD � BLIATERAL LUNG INJ. � INJURY TO MORE EXTREMITIES, + INJ. OF THE
THORAX � OP. TIME MORE THAN 6 HOURS � ARTERIAL INJ. HAEMODINAMIC INSTABILITY
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DAMAGE CONTROL SURGERY „SECOND HIT” – „THE SURGEON” � LONG TUBULAR BONE – STABILIZATION � CONTUNUOUS MONITORING � „MINIMAL” FAST SURGERY � PATIENT RESPONSE � INTRAARTICULAR, METAPHYSEAL FR. CAN WAIT � FIXATEUR EXTERNE IS ADVISED � EXPERIENCED TEAM � „LIFE BEFORE LIMB”
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DAMAGE CONTROL SURGERY PRIMER „AGRESSIVE „ STABILIZATION ? IF: � POLYTRAUMA ISS > 20 AND CHEST TRAUMA
AIS > 2 � POLYTRAUMA WITH ABDOMINAL THORACIC
INJ. AND SHOCK (RR < 90 HGMM) � ISS ≥ 40 � BILATERAL PULM. CONT. � ART. PULM. PERSSURE ON ADMISSION > 24 mm
MERCURY � ART. PULM. PRESSURE IN CASE OF
INTRAMEDULLARY STABILIZATTION RAISES MORE THAN 6 mm MERCURY
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INJURIES TO THE EXTREMITIES -24 HOURS � TRAUMATIC AMPUTATIONS � OPEN FRACTURES (II-III GR.) � FRACTURES WITH VASC. DAMAGE � INJURIES TO THE JOINTS � MULTIPLE PELVIC FR. � LUXATIONS (HIP, KNEE) � COMPARTEMENTE SY. � PROXIMAL TUBULAR BONES
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ABDOMINAL COMPARTEMENTE SYNDROME
THE RISE OF THE INTRAABDOMINAL PRESSURE CAUSE: USUALLY RETRO – INFRAPERITONEAL
BLEEDING CONSEQUENCE: DETERIORATION OF THE
ABDOMINAL BLOOD FLOW CONSEQUENCE: INTESTINALBARRIER FUNCTION
DETERIORATED CONSEQUENCE: TOXINEMIA, SIRS, MOF.
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AFTER 24 HOURS RE-‐EVALUATION
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MOF AND SIRS MULTIPLE ORGAN FAILURE SYSTEMIC INFLAMMATORY RESPONSE SYNDROME
MOF HYPOXIA, HYPOPERFUSIO, SHOCK „FIRST HIT”
BACTEREMIA TOXINS – INTESTINAL HYPOPERFUSION FRACTURE OF THE LONG TUBULAR BONES, STABILIZATION MEDIATORS „SECOND HIT” SIRS TWO OR MORE OF THESE FACTORS • TEMPERATURE > 38 OR < 36 • TACHYPNEA > 24/MIN • TACHYCARDIA > 90/ MIN • LEUCOCYTOSIS >12 000/ MM3 • LEUCUPENIA > 4000 OR YOUNG CELLS MOTE THAN 10%
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Infecting organism Tissue factor
Activation of coagulation
Factor VIIIa Factor Va
APC
inactivation
Endotoxin release
APC
inhibits
inhibits
IL- 2 TNFα Thrombin activation
Fibrin clot formation
MONOCYTE
IL-1 TNFα
Tissue factor
Neutrophil chemotaxis
Epithelial cell Epithelial cell
IL 6 release Nitric oxide release
MAJOR MEDIATORS OF CYTOKINE CASCADE IN SHOCK
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HOST RESPONE FOLLOWING TRAUMA
Proteins Free radicals Lipids Tnf IL-1
IL-6 IL-8
O2 H2O2 NO
Pge2 TXA2 PAF
Down-regulated Normo-regulated Up-regulated
Harmful effects „good” effects Harmful effects - No fever -Slight fever - High fever - No immune system -general immune - hypotension
stimulus system stim. - DIC -No bacterial kill bacterial kill shock
INFECTION HEALING SIRS
MONOCYTE
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TRIAGE A. DEGREE OF LIFE THREAT POSED BY THE
INJURY B. INJURY SEVERITY C. SALVAGEABILITY D. RESOURCES AVAILABLE E. TIME, DISTANCE, ENVIRONMENT
1 AMBULANCE UNIT FOR EVERY INJURED
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A. DEGREE OF LIFE THREAT.... A.B.C.D.E.
THE PATIENT HAVING AN ‘A’ PROBLEM TAKES PRIORITY OVER A PATIENT WITH A ‘C’ PROBLEM B. INJURY SEVERITY C. SALVAGEABILITY
4 GROUPS LIKEKIHOOD OF SURVIVAL
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4 GROUPS
1. NOT SALVAGEABLE (UNDER GIVEN CIRCUMSTANCES) 2. SEVERE LIFE THREATING INJURY BUT SALVAGEABLE 3. SEVERE BUT NOT LIFE THR. INJURY 4. LIGHT INJURY
2-3-4-1
1 HEAD GONE CHERNOBYL 2 AIRWAY INJURY, SEVERE BLEEDING 3 OPEN FEMUR FRACTURE 4 DISLOCATION OF A FINGER
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HAVE A NICE DAY