WHAT IS THE POINT OF THIS TALK? › uploads › sites › 2 › 2017 › 02 › Trauma_… · what...

WHAT IS THE POINT OF THIS TALK?

•1 HOUR OF CPD

•TAKE THE TRAUMA OUT OF TRAUMA

•IMPROVE OUR UNDERSTANDING OF TRAUMA SO WE CAN

PROVIDE BETTER CARE

WHAT IS TRAUMA?

TRAUMA = TISSUE INJURY

• Blunt trauma- RTA, kick, hit with

object

• Penetrating trauma- gunshot

wounds, stab wounds, bite wounds

• Environmental trauma- burns,

electrocution, frostbite

WHAT DO WE KNOW?

•TRAUMA >10% OF VET HOSP ADMISSIONS

•INVOLVES SERIOUS INJURIES IN APPROX. 35% OF CASES

•MORTALITY RATES APPROX. 10% IN DOGS

Ref: JVECC (2014) 24:1 pp 93-104

TRAUMA IMPACTS MANY LIVES!

WHAT ELSE DO WE KNOW?•UPTO 43% IN DOGS WITH BLUNT TRAUMA HAVE HAEMOABDOMEN

•INTRODUCTION OF FAST HAS INCREASED THE DETECTION OF POSTTRAUMA

HAEMORRHAGE

•DECREASED PLT COUNT PREDICTS BODY CAVITY HAEMORRHAGE

Ref: JVECC (2014) 24:1 pp 93-104

TRAUMA PATIENTS OFTEN BLEED INTERNALLY

WHAT DO WE KNOW?- MORE STATISTICS

• INCREASED LACTATE AND DECREASED BASE EXCESS PREDICT INCREASED MORTALITY

• aPTT WAS STRONGEST PREDICTOR OF DEATH IN ONE STUDY (SENS 67% SPEC 80%)

• STUDY RECENTLY- 13% RECEIVED GLUCOCORTICOIDS, 23% RECEIVED NSAIDS AND 3%

RECEIVED BOTH!!!!

Ref: JVECC (2014) 24:1 pp 93-104

BLOOD TESTS ARE GOOD! STEROIDS ARE BAD!!

HOW DO WE KNOW IT?

• HUMAN STUDIES

• RELEVANT TO ANIMAL POPULATIONS?

• DIFFERENCES- PARAMEDICS, BLOOD AND CT SCANNING, INJURY PATTERNS?

• OTHER HUMAN POPULATIONS- CHILDREN IN DEVELOPING COUNTRIES

• HUMANS USE ANIMAL MODELS- TRANSLATIONAL MEDICINE.

• VETCOT= VETERINARY COMMITTEE ON TRAUMA

EVIDENCE BASED MEDICINE

WHAT IS HAPPENING NOW?

• 26 ACTIVE VETERINARY TRAUMA CENTERS PARTICIPATING IN THE VETERINARY TRAUMA NETWORK

• A TOTAL OF 8,497 CASES HAVE BEEN ENTERED INTO THE TRAUMA REGISTRY TO DATE.

• VETCOT RESEARCH ON

• VALIDATING INJURY SCORES,

• PREDICTING TRANSFUSION REQUIREMENTS FOLLOWING TRAUMA

• PREVENTING HYPERFIBRINOLYSIS IN TRAUMA

MORE EVIDENCE BASED MEDICINE-COMING SOON…

HOW CAN WE IMPROVE TRAUMA CARE?

• 1. TRAUMA PATIENT CARE

• IMPROVED SURVIVAL,

• REDUCTION OF COMORBIDITIES

• DEVELOPMENT OF PROTOCOLS TO IMPROVE EFFICIENCY AND OUTCOMES.

• 2. RESEARCH COLLABORATIONS

• DEVELOPMENT OF EVIDENCE-BASED MEDICINE PROTOCOLS

• EVALUATION OF MINIMALLY INVASIVE, COST-EFFECTIVE INTERVENTIONS

• TRANSLATIONAL MEDICAL OPPORTUNITIES)

• 3. EDUCATION ON VETERINARY TRAUMA

VetCOT The Veterinary Trauma Initiative

TODAY’S FOCUS…

• BLUNT TRAUMA

• PATHOPHYSIOLOGY OF TRAUMA

• APPROACH TO TRAUMA CASES

• STABILISATION, MONITORING & INVESTIGATIONS

• NOT ORTHOPAEDICS!

• WHAT IS STRESSFUL ABOUT TRAUMA?

TAKING THE TRAUMA OUT OF TRAUMA

UNPREDICTABLE

DON’T say the

‘Q’ WORD!It is a well known fact that trauma cases are

most likely to occur

1) On a Friday afternoon

2) During breaks or attempted mealtimes

3) If anyone says it’s quiet

4) When you are short staffed and fully booked

TRAUMA TRAINING

• MANY OF US DIDN’T GET THIS

• RECENT ADVANCES IN TRAUMA CARE

• FEELING ‘OUT OF OUR DEPTH’

How

Can

Titanic

Help us

Save

Lives?

FEELING OUT OF OUR DEPTH?

BE PREPARED…

PLAN & PRACTICE, PRACTICE, PRACTICE…

TELEPHONE TRIAGE• TRAINING

• BRIEF DETAILS

• Contact Telephone Number

• ETA

• Animal’s Name/Surname

• Species (Breed also for dogs)

• FIRST AID INSTRUCTIONS (restraint, lifting,

bleeding)

• COMMUNICATION WITH CLINICAL STAFF

PRE-ARRIVAL

• ORGANISE TEAM

• WHO DEALS WITH THE TRAUMA PATIENT

• WHO DEALS WITH THE OWNER

• WHO WILL DEAL WITH EVERYTHING ELSE…

• WATCH OUT FOR THE ARRIVAL

• GET STUFF OUT- O2 TENT/CHECK FULL OXYGEN/ IV CATHETERS/MONITORING EQUIPMENT

LOOK OUT FOR WHAT’S COMING…

OWNER-ECTOMY

‘I’LL NEVER

LET GO…’(TITANIC MOVIE, 1997)

TRIAGE – PRIMARY SURVEY

•MAJOR BODY SYSTEMS

• CNS- MENTATION, PUPILS, POSTURE

• RESP- AIRWAY, RATE, PATTERN, SOUNDS

• CARDIOVASCULAR-MM, CRT, HEART

RATE/RHYTHM/SOUNDS, PULSES & TEMP

• RECORD IT!

TRIAGE – STABILISATION-A,B,C…

• A=AIRWAY #ET TUBE (ADVANCED AIRWAY

TECHNIQUES)

• B=BREATHING #OXYGEN #AMBU-BAG (CHEST

TAP)

• C=CIRCULATION #IV ACCESS (INTRAOSSEOUS,

JUGULAR)

• D=DRUGS=PAIN RELIEF

CLIENT CARE

• OWNER

• INFORMED CONSENT

• UPDATES

• THE CONCEPT OF ‘SHOCK’

• OTHER CLIENTS

• KEEP INFORMED OF WAIT

• OFFER TO RESCHEDULE NON-URGENT CASES

BE ‘KING OF THE WORLD’

WHAT LIES BENEATH?

TIME OF DEATH…

• 3 CRITICAL PERIODS WHEN PATIENTS DIE…

• IMMEDIATE- MINUTES

• INJURY TO BRAINSTEM, AORTA, HEART

• EARLY- HOURS

• HAEMORRHAGE, CNS INJURY

• LATE- DAYS

• COMPLICATIONS-INFECTION, MODS

}WE CAN SAVE THESE GUYS

PATHOPHYSIOLOGY OF TRAUMA

2 HIT

HYPOTHESIS…

2 IMPACTS = FIRST HIT

FIRST HIT

• FORCES APPLIED TO TISSUES

• STRETCHING

• COMPRESSION

• SHEARING

• MORE DAMAGE:

• MORE FORCE/ENERGY

• LESS ELASTICITY OF TISSUE

• LESS SURFACE AREA AVAILABLE TO ABSORB THE FORCE

NEWTON’S 2ND LAW

FORCE = MASS x ACCELERATION

HOLLOW ORGANS

• BLADDER, DIAPHRAGM, BOWELS, ALVEOLI

• COMPRESSION CAUSES INCREASED INTRALUMINAL PRESSURE

• POP!

SOLID ORGANS

• SPLEEN, LIVER, KIDNEYS

• INTRACAPSULAR HAEMORRHAGE

• RUPTURED CAPSULE & HAEMORRHAGE

• SHEARING OFF OF VESSEL ATTACHMENTS- RAPID ACCELERATION-DECELERATION,

HEAD TRAUMA

Coup Contre-coup

LOOKING MORE CLOSELY: 2ND HIT

PARIS

WHAT LIES BENEATH?

SHOCK• DEFINITION: ‘INADEQUATE CELLULAR ENERGY PRODUCTION’

USUALLY DUE TO POOR TISSUE PERFUSION

Compensated Shock

• Mild-moderate mental depression

• Normal-prolonged CRT

• Tachycardia (or bradycardia in cats)

• Tachypnoea

• Normal pulses

• Normal blood pressure

Decompensated Shock

• Depressed/Collapsed

• Prolonged CRT

• Pale mucous membranes

• Weak peripheral pulses

• Decreased blood pressure

TRAUMA DEATH TRIADcoagulopathy

Metabolic acidosisHypothermia

• VICIOUS CYCLE DUE TO SEVERE

HAEMORRHAGE

HYPOTHERMIA

• HYPOTHERMIA BELOW 34° DECREASES COAGULATION PROTEASE FUNCTIONAL ACTIVITY AND PLATELET

AGGREGATION

• HYPOTHERMIA IS DUE TO POOR PERFUSION AND EXACERBATED BY ADMINISTRATION OF COOL IV FLUIDS

• MOST LAB TESTS ARE RUN AT NORMAL BODY TEMPERATURE

• MONITORING TEMPERATURE IS ESSENTIAL IN TRAUMA CASES

ACIDOSIS

• ACTIVITY OF CLOTTING FACTORS REDUCED BY AS MUCH AS 50% AT PH 7.2

• METABOLIC ACIDOSIS IS CAUSED BY LACTIC ACID PRODUCTION PRODUCED BY

POORLY PERFUSED TISSUES

• LAB MACHINES TEST AT NORMAL BODY pH

• CAGESIDE LACTATE MACHINES USEFUL FOR MONITORING SHOCK AND EFFECTIVENESS

OF INTERVENTIONS

COAGULOPATHYAcute Trauma Coagulopathy (ATC)

= systemic state of hypocoagulation and

hyperfibrinolysis.

Theoretical causes:

• severe tissue injury

• shock-induced hypoperfusion

• systemic inflammation

• endothelial damage

MY TRAUMA PATIENT IS STILL BLEEDING BECAUSE…• A. IT HAS BLED OUT LOTS OF CLOTTING FACTORS AND PLATELETS

• B. IT HAS ALSO USED THEM UP TRYING NOT TO BLEED FROM ALL THE DAMAGED TISSUES

• C. IT HAS THAT WEIRD CLOTTING DISORDER FROM TRAUMA (ATC) WHICH GOES AROUND DISSOLVING

ALL THE CLOTS IT HAS ACTUALLY MANAGED TO MAKE AS WELL AS NOT WANTING TO CLOT

• D. CRYSTALLOID FLUIDS AND DILUTED THE REMAINING CLOTTING FACTORS

• E. IT IS TOO COLD

• F. IT’S BLOOD IS TOO ACIDIC

• G. ALL OF THE ABOVE!!!

HOW DO WE KNOW WHAT LIES BENEATH?

WHAT ARE WE LOOKING FOR?

•CONTINUED BLEEDING

•THORACIC INJURIES

•SEVERITY OF SHOCK

TRILOGY OF TRAUMA TESTING

•BLOOD TESTING

•FAST ULTRASOUND TECHNIQUES

•MONITORING

BLOOD TESTS

•LACTATE

•MINIMUM DATABASE (PCV, TS, GLU& BUN)

•ACID-BASE

•COAGS (PT & APTT)

•SMEAR (PLTS)

MONITORING

•SPO2

•BLOOD PRESSURE

•ECG

•MOD GCS

•PAIN SCORE

FAST SCANNINGNothing to do with the supermarket

FAST = Focussed Assessment with

Sonography for Trauma/Triage

Rapid technique for assessing trauma

patients

aFAST= abdominal FAST

tFAST=thoracic FAST

Also VetBlue (Veterinary Bedside Lung

Ultrasound Exam) an extension to tFAST

AFASTPOSITION- Right lateral Recumbancy

4 VIEWS:

DH- just caudal to sternum

SR- left flank just caudal to last rib

HR- right flank just caudal to last rib

CC- just cranial to pelvis

Highly Sensitive and Specific for

Free Abdominal Fluid

AFASTSpot the black triangles…

TFASTTip!- use sternal recumbency in

respiratory compromised patients

and a roll of towel or paper towel

under forelimbs for better probe

contact

TFAST

• TRAUMA WET LUNG =

PULMONARY CONTUSIONS

(UNLESS PROVEN

OTHERWISE)

TFAST

Glide Sign

Helps rule out

pneumothorax

TREATMENT

PRIMARY AIMS:

• PREVENT SUFFERING

• RESTORE & MAINTAIN PERFUSION TO VITAL ORGANS

• ENSURE ADEQUATE OXYGEN CARRYING CAPACITY OF BLOOD

SECONDARY AIMS

• DEFINITIVE TREATMENT OF INJURIES TO RESTORE FUNCTION

• PREVENT COMPLICATIONS

PREVENT SUFFERING- ANALGESIAPure µ- opioids-

• Methadone

• Morphine

• Fentanyl

Reversible with Naloxone

Consider Regional Analgesia- line blocks

No to Steroids and NSAIDS

PREVENT SUFFERING

•IMMOBILISE FRACTURES AND COVER WOUNDS

•CONSIDER BENZODIAZEPINES TO IMMOBILISE FRACTURES AND HEAD

TRAUMAS

•COMFORT/WARMTH/SLEEP/WATER/NUTRITION

OXYGEN SUPPORT

O2 tent for cats Nasal Prongs for dogs > nasal oxygen catheter if need to stay on oxygen

FLUID THERAPY

AIMS

• IMPROVE BLOOD PRESSURE TO PREVENT ORGAN DAMAGE (MAP>60mmHg)

• BUT NOT TOO HIGH OR RE-BLEEDING WILL OCCUR (MAP<70mmHg)

• FIELD PARAMETER OF IMPROVED MENTAL STATUS AND DORSAL PEDAL PULSE IN ANIMALS

• MAINTAINING PERFUSION HELPS PREVENT THE DEATH TRIAD

• CRYSTALLOID BOLUSES- LACTATED RINGERS SOLUTION

MONITOR BLOOD PRESSURE AND BLOOD LACTATE + PULSE QUALITY & MUCOUS MEMBRANES

FLUID THERAPY• TISSUE OXYGENATION REQUIRES BLOOD OXYGEN CARRYING CAPACITY

• PACKED RED BLOOD CELLS

• WHOLE BLOOD

• (OXYGLOBIN)

• HYPOCOAGULATION REQUIRES CLOTTING FACTORS

• FRESH FROZEN PLASMA

• WHOLE BLOOD

HEAD TRAUMA CONSIDERATIONS• PERFUSION OF BRAIN = MEAN ARTERIAL PRESSURE (MAP) – INTRACRANIAL PRESSURE

(ICP)

• TREAT HYPOTENSION FIRST

Increased ICP

SYSTEMIC BLOOD PRESSURE MUST BE HIGH ENOUGH TO PERFUSE BRAIN TISSUE SAP>90

Pushing blood into brain->

DAMAGE CONTROL CONCEPT• HYPOTENSIVE RESUS TO ALLOW ADEQUATE PERFUSION WITHOUT DISRUPTING

THROMBUS FORMATION.

• FRESH WARM BLOOD>BLOOD PRODUCT COMBO (PRBC, PLASMA,

PLATELETS)>CRYSTALLOIDS

• THE CHALLENGE IS NON-COMPRESSABLE HAEMORRHAGE

• NEED EARLY IDENTIFICATION

• NOT EVERYWHERE HAS LOTS OF BLOOD PRODUCTS AND PERSONNEL

• IF CANNOT STABILISE OR RELAPSE INTO SHOCK NEED SURGERY IMMEDIATELY

Following major haemorrhage…

HAEMOSTATIC RESUSCITATION• SEVERE HAEMORRHAGE REQUIRES HAEMOSTATIC RESUSCITATION

• BLOOD PRODUCTS INCLUDING

• SHED BLOOD (AUTOLOGOUS BLOOD TRANSFUSION)

• WHOLE BLOOD

• BLOOD COMPONENT THERAPY - RECOMMENDED 1:2 FFP:PRC

• WARMING

• IDENTIFY SOURCE & SECONDARY SITES, APPLY DIRECT PRESSURE/ABDOMINAL WRAP

ABDOMINAL WRAP• Include the hindlimbs!

• Use upto 48 hours with pressure of

20-25mmhg (to avoid abdominal

compartment syndrome)

• Survival rates increase using this in

haemoperitoneum.

• Contraindicated if diaphragmatic

hernia is present-pushes organs

into chest

AUTOLOGOUS BLOOD TRANSFUSION

Empty fluid bag with attached

giving set

20ml syringe

Large bore needle

AUTOLOGOUS BLOOD TRANSFUSION

POTENTIAL COMPLICATIONS/PRECAUTIONS

• INFECTION- ALTHOUGH ONE STUDY SHOWED EXCELLENT SURVIVAL EVEN WITH CONCURRENT BOWEL

PERFORATIONS

• NEOPLASTIC METASTASIS

• USE AN INLINE FILTER OR BLOOD ADMINISTRATION GIVING SET

• FOLLOW UP WITH FFP

AUTOLOGOUS BLOOD TRANSFUSION• TAKING SHED BLOOD FROM THE ABDOMEN OR THORAX AND TRANSFUSING IT

• In <1 hour the blood will have undergone

fibrinolysis- no anticoagulant required!

• Readily available source of pre-warmed type-

specific blood

• Collection is easy!

• Can give as fast as you want (don’t use a fluid

pump)

DAMAGE CONTROL SURGERY

• NOT definitive repair

• Aim is to control haemorrhage

• ‘Get in, Get out’

• Pack Abdomen, temporary closure

• ICU then second surgery

State of the art…

IMPORTANT POINTS

•BE PREPARED

•CHECK WHAT IS GOING ON BENEATH THE SURFACE

•PRACTICE FAST SCANNING

I want to be able to honestly tell the owner (and myself), ‘I did everything I could’

QUESTIONS????

Thanks for listening!