Penetrating trauma

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Information about Penetrating trauma
Health & Medicine

Published on May 3, 2014

Author: dengerin

Source: slideshare.net

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Lecture on penetrating trauma prepared for the Plains to Peaks RETAC conference in Limon, CO May 3, 2014.

Penetrating Trauma Ben Dengerink M.S., Paramedic, FP-C Education Coordinator Flight for Life Colorado Prepared for the 13th Annual Plains to Peaks RETAC EMS / Trauma Conference May 3, 2014 Limon, CO

Objectives • Discuss causes of death from trauma and ways to prevent this • Recognize critical penetrating trauma patients • Understand outcomes for penetrating head trauma • Review current medications and technologies for hemorrhage control • Review ABC’s in penetrating trauma (time permitting)

Introduction • What kills trauma patients? • Immobilization • History taking • Transport considerations • To the future! • <C>ABC‘s of penetrating trauma • Summary

When do people die from trauma? • Immediate death – DOA – Head, heart, aortic injury, etc.

When do people die from trauma? • Early death – 1-2 hours after injury – Subdural / epidural hematomas, hemo / pneumo-thorax, organ rupture, blood loss.

When do people die from trauma? • Late death – Many days after injury – Sepsis, MSOF, clots

When do people die from trauma? • Immediate Death – We can’t help you • Early Death • Late Death This is where EMS gets to make a difference!

What Kills Trauma Patients? • Hypoxia • Hypothermia • Hypovolemia STOP IT!

STOP IT! • Volume – Fluid bolus to SBP > 90 mmHg – Not too much! • Oxygen – Support airway to keep SpO2% > 93% • Keep them warm!

What Kills Trauma Patients? • And what can we do about it? – Basics: ABC’s – Paramedics and ALS care do not save trauma patients. – Good BLS care.

History • Important for long term care. • Get the best possible info on mechanism, etc. – Type of weapon, caliber – Pictures if you can’t bring it with you

History • Can guide suspicion in elderly: – Beta blockers, anticoagulants, new anticoagulants – Chronically under-resuscitated. Don’t be afraid to give fluid

Penetrating Head Trauma? • Survivability of penetrating head trauma is terrible. – As high as 93% mortality – Mortality highest when injury crosses the midline – Most within the first 3 hours (don’t make it to hospital) – 80-85% of those who arrive at hospital die within 2 days.

Penetrating Head Trauma? • Ominous signs: – GCS < 8 – Fixed, dilated pupils – Hypotension – Respiratory distress – CDI – Coagulopathy

The future! • TQ – You should have 2 – Quicker is better – Remains last resort when other methods have failed – 6 hours

The future! • Hemostatic agents • QuickClot, Hemcon, Combat Gauze • Shown to help with clot formation.

The future! • TXA • Plasma

Primary Survey

Hemorrhage • <C>ABC • Catastrophic Hemorrhage control before ABC’s

Airway • Can they talk? – You’re good • Head tilt / chin lift • OPA / NPA • C-spine protection? • Immobilize? Maybe not!

DON’T ALL TRAUMA PATIENTS GET BOARDED AND COLLARED? 2010 study of 45,000 trauma patients found mortality was twice as high as in those who were immobilized! “Spinal immobilization for patients with primarily penetrating trauma is rarely necessary. Consider immobilization when there is an apparent neurological deficit, an impaled foreign body, or other indication of specific cord damage.” Paramedic Protocol Guidelines El Paso County Edition, 11/13, p104.

Breathing • BVM • High flow O2? – Maybe not! – Titrate to > 90% SpO2% (EPCMS) – Unless obtunded / unresponsive, then give lots. • BVM / Intubate / etc.? • Decompression • Cover holes if air is moving.

Circulation • Hemorrhage control – Secure impaled object • Radial pulses =? • Skin color • Mentation • As much PIV as you can. – Small is ok if it is your only option. – IO?

Transport considerations • Rapid? – Penetrating trauma to abdomen/chest/ head/neck – Extremity trauma w/uncontrolled hemorrhage or disability • After C is when you should be moving to the ambulance. • Then to hospital (or wait for transport) and continue exam / tx.

Disability • ALOC? Why? – End organ perfusion? • BGL for ALL, even trauma. • Deficit distal to penetrating injury? – Complete – Brown-Sequard

Exposure / Environment • Remove clothing / visualize as needed – Not always practical. Always important. • Cover / keep warm (remember the killers of trauma patients).

Focused Exam (secondary survey) • After initial interventions and stabilization of VS. • Complete History as able. • Re-assess interventions

Summary • <C>ABC • Volume, O2, Warmth • No spinal immobilization unless clearly indicated • Rapid transport for chest / abd / head trauma, uncontrolled bleeding, extremity disability, airway compromise.

References • Links to this presentation and more:http://bit.ly/ffltrauma • Trauma. Accidental and intentional injuries account for more years of life lost in the U.S. than cancer and heart disease. Among the prescribed remedies are improved preventive efforts, speedier surgery and further research. http://www.ncbi.nlm.nih.gov/pubmed/6623052 – This is shifting to a bimodal distribution as we get better at treating early death. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943446/ • Guidelines for the Institution of Damage Control in Trauma Patients. http://www.itaccs.com/traumacare/archive/05_04_Fall_2005/Fall2005.pdf • Maybe don’t immobilize your trauma patients! – http://www.jems.com/article/patient-care/research-suggests-time-change-prehospita – http://www.ncbi.nlm.nih.gov/pubmed/20065766 – http://www.emsworld.com/article/10964204/prehospital-spinal-immobilization • Spine immobilization in penetrating trauma: more harm than good? http://www.ncbi.nlm.nih.gov/pubmed/20065766 • <C>ABC; controlling catastrophic hemorrhage before ABC’s: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579588/ • Brown Sequard Syndrome: http://en.wikipedia.org/wiki/Brown-S%C3%A9quard_syndrome • Principles of Ballistics and Penetrating Trauma: http://books.google.com/books?id=mOJpd- Sy1kgC&pg=PA188&dq=%22Principles+of+Ballistics+and+Penetrating+trauma%22&hl=en&sa=X&ei=sN9fU _q1IY2ZyAS0m4GwDA&ved=0CC0Q6AEwAA#v=onepage&q=%22Principles%20of%20Ballistics%20and%2 0Penetrating%20trauma%22&f=false

Thank you! bendengerink@centura.org (720) 321-3926

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