VetVine - Trauma the First 15 Minutes

8/12/2019 VetVine - Trauma the First 15 Minutes

1/27

12/17/13

1

Trauma: TheFirst 15 Minutes

Elisa M. Mazzaferro, MS, DVM, PhD, DACVECC

Shelby 3 year old F(S)

Beagle Nonambulatory after

vehicular trauma No loss of

consciousness No prior health

problems


2/27

12/17/13

2

Physical Examination

Pale mm, prolonged CRT Mild epistaxis Tachycardic Clear lung sounds, eupneic Miotic pupils, sluggishly responsive to

light

Crepitus in left coxofemoral area Multiple skin abrasions

Problem List Miotic pupils Coxofemoral crepitus Tachycardia with pale mucous

membranes Skin abrasions

Epistaxis


3/27

12/17/13

3

ABCs of Trauma

Airway Breathing Circulation Disability

Oxygen DeliveryDO 2 = Q x C aO 2

Q = Heart Rate x Stroke Volume

Preload Afterload Contractility

C aO2 = [1.34 x Hb x S aO 2] + [0.003xP aO 2]


4/27

12/17/13

4

Treatment to Improve Oxygen

DeliveryDO 2 = Q x C aO 2

Q = Heart Rate x Stroke Volume

Preload Afterload Contractility

C aO2 = [1.34 x Hb x S aO 2] + [0.003x P aO 2]

Crystalloids

Colloids

Fluids

Antiarrhythmics

Whole Blood

Packed RBCs

Oxyglobin

Inotropes

Oxygen supplementation

Analgesia What about the head

trauma? What analgesic

should we give?

Abrasion and Miosis =Head Trauma


5/27

12/17/13

5

Analgesia

Always use judiciously

Dose Response Curve of Opioids

FentOxy

Torb

Bup

Mor

DOSE

% A

n a

l g e s

i a


6/27

12/17/13

6

Analgesics

Circulation Fluid Therapy Large (shock) bolus dosing of

crystalloid, hypertonic or colloidfluids can raise pressures tosupernormal levels

Newly formed clots to break offdamaged vessels

Dilutional coagulopathy


7/27

12/17/13

7

Fluid Resuscitation During Shock

First identify underlying possiblecomplicating factors: Closed cavity hemorrhage Pulmonary contusions Head/brain trauma

Cardiac dysfunction

Phases of Fluid Administration

Emergency phase Rehydration phase Maintenance phase


8/27

12/17/13

8

Early Compensatory Shock

15 30% loss of circulation volume Hyperemic mucous membranes Tachycardia Vasoconstriction Rapid CRT Normal to increased mean arterial pressure

Early Decompensatory Shock 30 40% loss of circulating volume Pale mucous membranes Tachycardia Prolonged CRT Normal to decreased mean arterial

pressure


9/27

12/17/13

9

Late Decompensatory Shock

> 40% loss of circulating volume Pale to grey mucous membranes Prolonged CRT Normal to decreased heart rate Decreased mean arterial pressure Poor pulse quality

Hypothermia

Over-treatment Pulmonary contusions worsen with

overzealous fluid therapy Large volumes quickly can increase

fluid loss into damaged tissues Iatrogenic interstitial fluid overload

worsens hypoxemia and oxygendelivery

Iatrogenic dilutional coagulopathy


10/27

12/17/13

10

Rapid Volume Resuscitation

IV or IO are the only ways to go SQ fluids not appropriate for volume

replacement in an animal in shock

Be prepared to infuse one whole bloodvolume per hour if a healthyvasculature is present

90 mls/kg/hour for dogs 40-45 mls/kg/hour for cats

Rapid Volume Resuscitation Be prepared to infuse one whole

blood volume per hour if a healthyvasculature is present 90 mls/kg/hour for dogs 40 to 45 mls/kg/hour for cats


11/27

12/17/13

11

Rapid Volume Resuscitation

Start with ! of the calculatedshock dose, then reassessperfusion parameters Heart rate Blood pressure

Capillary refill time Urine output

Rapid Volume Resuscitation Helpful Hint

For dogs, take their body weightin POUNDS, and add a zero

This equals ! shock dose offluids!


12/27

12/17/13

12

Small Volume Resuscitation

Colloidal administration 5 ml/kg bolus

Reassessment of perfusionparameters

Used in: Head trauma or closed

cavity hemorrhage Pulmonary contusions

Hypotensive Resuscitation Limited volume

Conservative volumes to controlhemorrhage

Permissive hypotension Delayed resuscitation

No volume resuscitation untilhemorrhage controlled


13/27

12/17/13

13

Hypertonic Saline (7.5% NaCl)

3 5 ml/kg IV over10 15 minutes

Synergistic withDextran-70

Effects last 30minutes

Improved cerebralperfusion

Pneumothorax Treatment Thoracocentesis

Diagnosis andtreatment

Thoracostomy tube Continuous

production

Multiplethoracocentesis


14/27

12/17/13

14

Thoracocentesis Supplies Antimicrobial

scrub Clippers/ blades 60 ml syringe 3-way stopcock Extension tubing Red/purple topped

tubes 22 g needles

Thoracocentesis

Clip a 10 cm square area in the middle of thethorax.


15/27

12/17/13

15

Thoracocentesis

Palpate the intercostal space in the middle of the clippedarea. Insert the needle.

Thoracocentesis

As soon as the needle enters the pleural space, place theneedle parallel with the body wall, to avoid iatrogenic lung

laceration. Make sure that the bevel of the needle is directedinwards.


16/27

12/17/13

16

Thoracocentesis

Have an assistant draw off any air or fluid that is present.

Spackman CJA, et. al. JAVMA 1984

Respiratory Injury 57% of dogs with multiple trauma Pulmonary contusions Pneumothorax Fractured ribs Diaphragmatic hernia


17/27

12/17/13

17

Pulmonary Contusions

Complication of blunt chest trauma Under wounds, rib fractures or

without obvious external injury Alveoli fill with blood and fluid

Intrapulmonary shunt Hypoxemia

Pulmonary Contusions Interstitial to alveolar

lung pattern

May not be evidenton early radiographs

Radiographic changesmay continue to developfor 2 to 24 hours


18/27

12/17/13

18

Anything Else?


19/27

12/17/13

19

Abdominocentesis

Clippers andblades

Antimicrobialscrub

20 22 gaugeneedles

3 ml syringe Red and purple

topped tubes Culturettes

Other Diagnostics


20/27

12/17/13

20

What Should We Do With This?

Making a Diagnosis of

Uroabdomen


21/27

12/17/13

21

Making a Diagnosis of

Uroabdomen

Other Diagnostics SpO2 = 87% on

room air


22/27

12/17/13

22

Oxyhemoglobin DissociationCurve

10 20 30 40 50 60 70 80 90 100

P aO 2 in mm Hg

S p

O 2

10

20

30

40

50

60

70

80

90

100

P aO 2 SpO 2100 97.5

80 96.5

70 92.5

60 89

50 83.5

40 75

30 57

20 35

10 13.5

What About SupplementalOxygen?


23/27

12/17/13

23

Other Diagnostics

S pO 2 later worsenedto 80% on 40% nasaloxygen

NasopharyngealOxygen

What Else Can We Do? Other


24/27

12/17/13

24

Neurologic Status

When Should We Fix Her Leg?


25/27

12/17/13

25

How Do You Want ToAnesthetize Her?

Epidural


26/27

12/17/13

26

Doses

Duramorph: 0.1mg/kg Bupivacaine (0.5%):

K-9 1cc/4.5kgFeline 1cc/7kg

Dilution 0.33ml/kg 6ml total

Post-Op Fentanyl IV CRI 3 7 mcg/kg/hour Urinary catheter Rimadyl 2.2 mg/kg

PO BID Transitioned to

Tramadol 24 hourspost-op, then home


27/27

12/17/13

Documents

VetVine - Trauma the First 15 Minutes