Role of the Nurse in Trauma Resuscitation - Shands Professionals

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Welcome to Trauma Tracks

2010

Role of the Nurse in Trauma Resuscitation Michele Ziglar MSN RN

Director Trauma amp Aeromedical Services Shands at the University of Florida

OBJECTIVES

bull At the end of this lecture the attendee will be able tondash Describe aspects of the nursing

role in trauma resuscitation

ndash Discuss assessment and management priorities that optimize trauma resuscitation

ndash Geographical Service Area= 1 mill+ people 12 counties

ndash 12000+ trauma admissions

Average 65 trauma patients daily84 adults vs 16 peds70 male28 in (16-29 yr) old age group77 blunt trauma

ndash 33 with ISS gt 15ndash 49 mortality rate

Shands at UF Level I Trauma Center (Oct 1 2004 ndash December 31 2009)

Source SUF Trauma Registry

Green line represents equal distance between Shands at UF and other Level I Trauma Centers

Current Outcomes for CY 2009

bull Volume= 2578 patients

bull 31 of patients with ISSgt15

bull ICU LOS= 24 days

bull Hospital LOS= 58 days ndash (92 index internal ACHA Methodology)

bull 441 mortality rate overall (NTDB 48 1485098 pts)ndash (93 index internal ACHA Methodology)

FRAMEWORKbull Readiness hyper-vigilance consistent

organization and clear cut communication produces effective outcomes

bull We should all know our A B C Dsbull Practice makes perfectbull The success of a trauma resuscitation is only

as good as its team AND

A proficient trauma team cannot function without a ldquowell-skilledrdquo trauma nurse

ProfileCredentials of a Trauma Patient

bull Risk taking behaviorndash Drinking distracted

speed out for funhellipbull Male vs Female

ndash 75 malebull Average age (young)

ndash Mean age 17bull Mechanism frequently

Blunt trauma and acutely episodic

ProfileCredentials of a Trauma Nurse

bull Assertive behaviorndash Autonomous focused

passionatehellipbull Female vs Male

ndash 75 femalebull Average age (wise)

ndash Mean age 46bull Mechanism frequently

Continuous care for trauma patients is chronically perpetual

Framework Readiness hyper-vigilance-- produces effective outcomesbull Pre-established

trauma system based on experience from military

bull 2020 vision from a distance-- expect the unexpected

ldquoRed-tailed hawkrdquo

Framework Consistent organization and clear cut communication produces effective outcomes

bull Well established and maintained clear roles and goals

bull Similar training- street through hospital

bull Effective function of the team begins with the Team leader

RRT

CC TechSr Resident

Jr Resident

EM Resident

Medical Student(HampPOrders)

Nurse 2(Scribe)

AttendingTrauma

Sr ResidentPGY5PGY4PGY3

FAST

Introducer-Subclavian

A-line-Femoral Artery

EM AttendingED ResidentAirway- edentulate tongue RSI

Breathing- end tidal CO2 ambu NGOGPupils TMrsquos

Suturing scalp lac (no staples)

Nurse 1Change field IVs to warm IVs Second IV Manual BP Vital signs including core temp Warming measures

Attaches monitors BP pulse oximetry EKG electrodes End tidal CO2

Monitors amp reports physiologic parametersAssists with procedures as appropriate

Prepares patient for transportObtains equipment supplies medications

X-RaysCXR Pelvis

JR ResidentVacutainer

Femoral ArteryABGs

Lactic AcidHgbHct

BMPPTPTT-Elderly CHI ampAnticoagulantsBA- all drivers

ETOH suspicionRectal Exam

Foley Catheter

Nurse 2 (Scribe)Documentation on Trauma Flow Sheet Ensures overall coordination of room Completes lab slips applies patient

bracelet places phone calls for orders diagnostics admission

RadiologyTech

RRTAirway adjuncts

SuctioningEnd tidal CO2

Ambu

FAST

Nurse 1

CC TechAttaches monitors BP pulse

oximetry EKG electrodes End tidal

CO2Performs CPR

Assists with procedure set-upsObtains equipment and

supplies

Charge NurseAssists with coordination

of patient care

i-STAT AttendingEM

New TowerNew Tower

NurseNursersquorsquos Stations Station

Trauma Resuscitation RoomTrauma Resuscitation Room

Trauma Resuscitation RoomTrauma Resuscitation Room

Trauma Center Trauma Center EntranceEntrance

Main EntranceMain Entrance

Alberta-- first trauma alert

Situation Awareness

Detection(Perception)

Patient

Team

Environment

Tools

Diagnosis

Prediction

PremiseCause of instability must be

recognized and corrected quickly by using a systematic approach

It is important to identify and prioritize systemic compromise

Most Potentially Preventable Trauma Deaths are related to

bull Airway obstruction

bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

1 All trauma patients need oxygen until proven otherwise

2 All trauma patients are bleeding until proven otherwise

3 All trauma patients have a cervical spine injury until proven otherwise

4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

Optimizing Resuscitation Across the Continuum

bull Prehospital Phasendash Key patient

information must be communicated

bull Mechanismbull GCSbull Vital Signsbull Interventions

ndash Be familiar with modalities and controversies

Pay attention to episodic events of hypotension

Airway All trauma patients need oxygen until proven otherwise

bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

of breathingmaximizes O2 delivery

ndash Corrects acid base disturbances

ndash Allow clinician to focus on other life-threatening issues

Prehospital Intubation

bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

Prehospital Intubation

bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

The impact of prehospital ventilation on outcome after severe traumatic brain injury

Cusheri et al JTrauma 2007 Jun62(6)1330-6

BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

with lower mortality after severe TBI

Bridge Devices 2010

LMAKing Airway

Combitube

Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

25 of all trauma deathsbull Understand the significance of

patternsndash 1st and 2nd rib fxs abdominal breathing

bull Treat the pneumo before ETTbull Life-threatening thoracic

injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

1

2

CT Scan for thoracic trauma

An occult pneumothorax seen on a CT scan that was not detected on a plain

anteroposterior supine chest radiograph

bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

Hemorrhage All trauma patients are bleeding until proven otherwise

bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

bull Prevent shock by arresting the bleeding

bull Mandates the earliest possible ldquogoal directed therapyrdquo

Hemorrhage PEARLbull Recognize trouble

ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

increases morbidity and doubles mortality especially in head injured patients

bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

Hemorrhage 5 Anatomic Areas of Origin

Kirkpatrick AW et al Can J Surg 200851(1)57-69

Hemorrhage Importance of Lactate amp BD

bull For Resuscitation to Occurndash Adequate perfusion and

ndash Tissue oxygenation must be restored

bull Measures Directed atndash Enhancing O2 transport and O2 uptake

ndash Controlling the bleeding

Persistent Acidosis Indicates

bull Continued bleeding

bull Inadequate resuscitation

bull Myocardial dysfunction

dArr

serum pH (735 ndash 745)uArr

base deficit (2 to -2)uArr

serum lactate (04 ndash 18)

Base Deficit Categories

bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

A base deficit of -6 is a marker of severeinjury amp significant mortality

Uses of Base Deficit in Trauma Care

bull Excellent correlation of base deficit to lactate and pH

bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

bull Assessing shock and efficacy of resuscitation

bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

Resuscitation End Points

bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

ndash Mentation

ndash UO

ndash Labs base deficit serum lactate serum pH

Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

urine output remain standard of carebull Uncompensated shock requires additional

resuscitationbull However after normalizing the above up to 85 of

severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

bull Better markers of adequate resuscitation are needed

Goal Directed Therapy PEARLbull Recognize trouble

ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

ndash Anticoagulantsndash Beta blockers

bull Early invasive monitoringbull Follow resuscitation goals

Optimizing Prehospital Resuscitation

bull Low volume fluid administration in penetrating injuries

bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

sheetsbinderbull Tourniquetsbull Scoop and run transports

based on ldquogolden hourrdquo

ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

Optimizing ResuscitationOptimizing Resuscitation

Prehospital Topicals 2010 Hemostatic Field Dressing

bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

Tourniquets 2010

40

Indications for Tourniquetsbull Stop bleeding when life-

threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

bull Stop bleeding with traumatic amputation

Intraosseous Infusion Devices 2010

EZ-IO

FAST1

Blood Substitutes 2010

bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

bull Ready for prime time ndash not yet but soon - maybe

bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

ndash JAMA - April 28 2008

Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

bull Direct pressure to all external bleeding

bull Rapid suturing of all scalp and facial wounds

bull Rapid application of ThomasHare Traction splints for femur fx

bull Binder for pelvic fxbull Rapid reduction and pressure

dressings of mangled extremities

Pelvic Binders 2010

Optimizing ED Trauma Resuscitation (cont)

bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

bull Use FAST to rapidly detect intra-abdominal fluid

bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

floor during chest tube insertion

Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

bull Intervene early in resuscitation to STOP bleeding

bull Conserve blood earlybull Aggressive rapid and efficient operative

interventionsbull Use novel methods to STOP bleeding in the

operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

coagulopathy

bull Controversialndash Whether to administer type and how much

bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

Optimizing ED Trauma Resuscitation- Fluid Resuscitation

MTP Process Shands at UF

Attending Fellow Chief ResidentActing Chief Resident initiates MTP

amp notifies designated RN

Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

runner to BB with cross amp match

MTP runner delivers blood products to designated RN

Ismore MTPneeded

EDOR ICU

Designated RN assures bloodadministered per MD order

Designated RN assures blood administered per MD order

Designated RN sends MTP runner for more blood

MTP site

Ispt to be

transported withblood

Designated RN transportsblood with pt to location(ORICU)

END

END

END

YES NO

YES

NO

ED = Nurse ScribeOR = Circ RN notifies

Charge Nurse

62406

ED Thoracotomy for Moribund Patients

bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

bull Aortic cross-clamping

Optimizing Resuscitation Across the Continuum

bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

bullbull RegroupRegroup

Damage Control Focus on Physiology

bull Major paradigm shift in operative management of devastating injuries

bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

Damage Control Patient Selectionbull Instability

bull Hypothermia (lt 34deg C)

bull Coagulopathy

bull Acidosis (pHlt 72BD -8)

bull Major traumaAvoid ldquoground zero of damage control

(physiological decompensation)

Neurological All unconscious trauma patients have brain injury until proven otherwise

bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

bull Avoid hypotension in brain injured patients= poor outcome

bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

bull Urgent CT and expert neurosurgical care is a must

Questions

Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

Summary and Conclusionsbull It is truly all about the

patient

bull Team effort and framework is needed by design

bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

bull Trauma centers save lives

  • Welcome to Trauma Tracks
  • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
  • OBJECTIVES
  • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
  • Current Outcomes for CY 2009
  • FRAMEWORK
  • ProfileCredentials of a Trauma Patient
  • FrameworkReadiness hyper-vigilance-- produces effective outcomes
  • FrameworkConsistent organization and clear cut communication produces effective outcomes
  • Slide Number 10
  • Slide Number 11
  • Slide Number 12
  • Slide Number 13
  • Situation Awareness
  • Most Potentially Preventable Trauma Deaths are related to
  • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
  • Optimizing Resuscitation Across the Continuum
  • Airway All trauma patients need oxygen until proven otherwise
  • Airway All unstable trauma patients need a definitive airway
  • Prehospital Intubation
  • Prehospital Intubation
  • The impact of prehospital ventilation on outcome after severe traumatic brain injury
  • Bridge Devices 2010
  • Breathing All trauma patients need oxygen until proven otherwise
  • CT Scan for thoracic trauma
  • Hemorrhage All trauma patients are bleeding until proven otherwise
  • Hemorrhage PEARL
  • Hemorrhage 5 Anatomic Areas of Origin
  • Hemorrhage Importance of Lactate amp BD
  • Persistent Acidosis Indicates
  • Base Deficit Categories
  • Uses of Base Deficit in Trauma Care
  • Resuscitation End Points
  • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
  • Goal Directed Therapy PEARL
  • Optimizing Prehospital Resuscitation
  • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
  • PrehospitalTopicals 2010Hemostatic Field Dressing
  • Tourniquets 2010
  • Indications for Tourniquets
  • Intraosseous Infusion Devices 2010
  • Blood Substitutes 2010
  • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
  • Pelvic Binders 2010
  • Optimizing ED Trauma Resuscitation (cont)
  • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
  • Slide Number 47
  • Slide Number 48
  • ED Thoracotomy for Moribund Patients
  • Optimizing Resuscitation Across the Continuum
  • Damage ControlFocus on Physiology
  • Damage Control Patient Selection
  • Neurological All unconscious trauma patients have brain injury until proven otherwise
  • Questions
  • Summary and Conclusions

    Role of the Nurse in Trauma Resuscitation Michele Ziglar MSN RN

    Director Trauma amp Aeromedical Services Shands at the University of Florida

    OBJECTIVES

    bull At the end of this lecture the attendee will be able tondash Describe aspects of the nursing

    role in trauma resuscitation

    ndash Discuss assessment and management priorities that optimize trauma resuscitation

    ndash Geographical Service Area= 1 mill+ people 12 counties

    ndash 12000+ trauma admissions

    Average 65 trauma patients daily84 adults vs 16 peds70 male28 in (16-29 yr) old age group77 blunt trauma

    ndash 33 with ISS gt 15ndash 49 mortality rate

    Shands at UF Level I Trauma Center (Oct 1 2004 ndash December 31 2009)

    Source SUF Trauma Registry

    Green line represents equal distance between Shands at UF and other Level I Trauma Centers

    Current Outcomes for CY 2009

    bull Volume= 2578 patients

    bull 31 of patients with ISSgt15

    bull ICU LOS= 24 days

    bull Hospital LOS= 58 days ndash (92 index internal ACHA Methodology)

    bull 441 mortality rate overall (NTDB 48 1485098 pts)ndash (93 index internal ACHA Methodology)

    FRAMEWORKbull Readiness hyper-vigilance consistent

    organization and clear cut communication produces effective outcomes

    bull We should all know our A B C Dsbull Practice makes perfectbull The success of a trauma resuscitation is only

    as good as its team AND

    A proficient trauma team cannot function without a ldquowell-skilledrdquo trauma nurse

    ProfileCredentials of a Trauma Patient

    bull Risk taking behaviorndash Drinking distracted

    speed out for funhellipbull Male vs Female

    ndash 75 malebull Average age (young)

    ndash Mean age 17bull Mechanism frequently

    Blunt trauma and acutely episodic

    ProfileCredentials of a Trauma Nurse

    bull Assertive behaviorndash Autonomous focused

    passionatehellipbull Female vs Male

    ndash 75 femalebull Average age (wise)

    ndash Mean age 46bull Mechanism frequently

    Continuous care for trauma patients is chronically perpetual

    Framework Readiness hyper-vigilance-- produces effective outcomesbull Pre-established

    trauma system based on experience from military

    bull 2020 vision from a distance-- expect the unexpected

    ldquoRed-tailed hawkrdquo

    Framework Consistent organization and clear cut communication produces effective outcomes

    bull Well established and maintained clear roles and goals

    bull Similar training- street through hospital

    bull Effective function of the team begins with the Team leader

    RRT

    CC TechSr Resident

    Jr Resident

    EM Resident

    Medical Student(HampPOrders)

    Nurse 2(Scribe)

    AttendingTrauma

    Sr ResidentPGY5PGY4PGY3

    FAST

    Introducer-Subclavian

    A-line-Femoral Artery

    EM AttendingED ResidentAirway- edentulate tongue RSI

    Breathing- end tidal CO2 ambu NGOGPupils TMrsquos

    Suturing scalp lac (no staples)

    Nurse 1Change field IVs to warm IVs Second IV Manual BP Vital signs including core temp Warming measures

    Attaches monitors BP pulse oximetry EKG electrodes End tidal CO2

    Monitors amp reports physiologic parametersAssists with procedures as appropriate

    Prepares patient for transportObtains equipment supplies medications

    X-RaysCXR Pelvis

    JR ResidentVacutainer

    Femoral ArteryABGs

    Lactic AcidHgbHct

    BMPPTPTT-Elderly CHI ampAnticoagulantsBA- all drivers

    ETOH suspicionRectal Exam

    Foley Catheter

    Nurse 2 (Scribe)Documentation on Trauma Flow Sheet Ensures overall coordination of room Completes lab slips applies patient

    bracelet places phone calls for orders diagnostics admission

    RadiologyTech

    RRTAirway adjuncts

    SuctioningEnd tidal CO2

    Ambu

    FAST

    Nurse 1

    CC TechAttaches monitors BP pulse

    oximetry EKG electrodes End tidal

    CO2Performs CPR

    Assists with procedure set-upsObtains equipment and

    supplies

    Charge NurseAssists with coordination

    of patient care

    i-STAT AttendingEM

    New TowerNew Tower

    NurseNursersquorsquos Stations Station

    Trauma Resuscitation RoomTrauma Resuscitation Room

    Trauma Resuscitation RoomTrauma Resuscitation Room

    Trauma Center Trauma Center EntranceEntrance

    Main EntranceMain Entrance

    Alberta-- first trauma alert

    Situation Awareness

    Detection(Perception)

    Patient

    Team

    Environment

    Tools

    Diagnosis

    Prediction

    PremiseCause of instability must be

    recognized and corrected quickly by using a systematic approach

    It is important to identify and prioritize systemic compromise

    Most Potentially Preventable Trauma Deaths are related to

    bull Airway obstruction

    bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

    Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

    1 All trauma patients need oxygen until proven otherwise

    2 All trauma patients are bleeding until proven otherwise

    3 All trauma patients have a cervical spine injury until proven otherwise

    4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

    Optimizing Resuscitation Across the Continuum

    bull Prehospital Phasendash Key patient

    information must be communicated

    bull Mechanismbull GCSbull Vital Signsbull Interventions

    ndash Be familiar with modalities and controversies

    Pay attention to episodic events of hypotension

    Airway All trauma patients need oxygen until proven otherwise

    bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

    bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

    bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

    Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

    unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

    of breathingmaximizes O2 delivery

    ndash Corrects acid base disturbances

    ndash Allow clinician to focus on other life-threatening issues

    Prehospital Intubation

    bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

    bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

    Prehospital Intubation

    bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

    bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

    bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

    The impact of prehospital ventilation on outcome after severe traumatic brain injury

    Cusheri et al JTrauma 2007 Jun62(6)1330-6

    BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

    determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

    impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

    with lower mortality after severe TBI

    Bridge Devices 2010

    LMAKing Airway

    Combitube

    Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

    25 of all trauma deathsbull Understand the significance of

    patternsndash 1st and 2nd rib fxs abdominal breathing

    bull Treat the pneumo before ETTbull Life-threatening thoracic

    injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

    1

    2

    CT Scan for thoracic trauma

    An occult pneumothorax seen on a CT scan that was not detected on a plain

    anteroposterior supine chest radiograph

    bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

    bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

    Hemorrhage All trauma patients are bleeding until proven otherwise

    bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

    bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

    bull Prevent shock by arresting the bleeding

    bull Mandates the earliest possible ldquogoal directed therapyrdquo

    Hemorrhage PEARLbull Recognize trouble

    ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

    increases morbidity and doubles mortality especially in head injured patients

    bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

    ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

    Hemorrhage 5 Anatomic Areas of Origin

    Kirkpatrick AW et al Can J Surg 200851(1)57-69

    Hemorrhage Importance of Lactate amp BD

    bull For Resuscitation to Occurndash Adequate perfusion and

    ndash Tissue oxygenation must be restored

    bull Measures Directed atndash Enhancing O2 transport and O2 uptake

    ndash Controlling the bleeding

    Persistent Acidosis Indicates

    bull Continued bleeding

    bull Inadequate resuscitation

    bull Myocardial dysfunction

    dArr

    serum pH (735 ndash 745)uArr

    base deficit (2 to -2)uArr

    serum lactate (04 ndash 18)

    Base Deficit Categories

    bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

    A base deficit of -6 is a marker of severeinjury amp significant mortality

    Uses of Base Deficit in Trauma Care

    bull Excellent correlation of base deficit to lactate and pH

    bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

    bull Assessing shock and efficacy of resuscitation

    bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

    Resuscitation End Points

    bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

    ndash Mentation

    ndash UO

    ndash Labs base deficit serum lactate serum pH

    Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

    urine output remain standard of carebull Uncompensated shock requires additional

    resuscitationbull However after normalizing the above up to 85 of

    severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

    bull Better markers of adequate resuscitation are needed

    Goal Directed Therapy PEARLbull Recognize trouble

    ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

    ndash Anticoagulantsndash Beta blockers

    bull Early invasive monitoringbull Follow resuscitation goals

    Optimizing Prehospital Resuscitation

    bull Low volume fluid administration in penetrating injuries

    bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

    sheetsbinderbull Tourniquetsbull Scoop and run transports

    based on ldquogolden hourrdquo

    ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

    bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

    bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

    Optimizing ResuscitationOptimizing Resuscitation

    Prehospital Topicals 2010 Hemostatic Field Dressing

    bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

    bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

    Tourniquets 2010

    40

    Indications for Tourniquetsbull Stop bleeding when life-

    threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

    bull Stop bleeding with traumatic amputation

    Intraosseous Infusion Devices 2010

    EZ-IO

    FAST1

    Blood Substitutes 2010

    bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

    bull Ready for prime time ndash not yet but soon - maybe

    bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

    ndash JAMA - April 28 2008

    Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

    bull Direct pressure to all external bleeding

    bull Rapid suturing of all scalp and facial wounds

    bull Rapid application of ThomasHare Traction splints for femur fx

    bull Binder for pelvic fxbull Rapid reduction and pressure

    dressings of mangled extremities

    Pelvic Binders 2010

    Optimizing ED Trauma Resuscitation (cont)

    bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

    Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

    bull Use FAST to rapidly detect intra-abdominal fluid

    bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

    floor during chest tube insertion

    Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

    bull Intervene early in resuscitation to STOP bleeding

    bull Conserve blood earlybull Aggressive rapid and efficient operative

    interventionsbull Use novel methods to STOP bleeding in the

    operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

    coagulopathy

    bull Controversialndash Whether to administer type and how much

    bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

    Optimizing ED Trauma Resuscitation- Fluid Resuscitation

    MTP Process Shands at UF

    Attending Fellow Chief ResidentActing Chief Resident initiates MTP

    amp notifies designated RN

    Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

    refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

    Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

    runner to BB with cross amp match

    MTP runner delivers blood products to designated RN

    Ismore MTPneeded

    EDOR ICU

    Designated RN assures bloodadministered per MD order

    Designated RN assures blood administered per MD order

    Designated RN sends MTP runner for more blood

    MTP site

    Ispt to be

    transported withblood

    Designated RN transportsblood with pt to location(ORICU)

    END

    END

    END

    YES NO

    YES

    NO

    ED = Nurse ScribeOR = Circ RN notifies

    Charge Nurse

    62406

    ED Thoracotomy for Moribund Patients

    bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

    bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

    bull Aortic cross-clamping

    Optimizing Resuscitation Across the Continuum

    bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

    triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

    bullbull RegroupRegroup

    Damage Control Focus on Physiology

    bull Major paradigm shift in operative management of devastating injuries

    bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

    temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

    ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

    Damage Control Patient Selectionbull Instability

    bull Hypothermia (lt 34deg C)

    bull Coagulopathy

    bull Acidosis (pHlt 72BD -8)

    bull Major traumaAvoid ldquoground zero of damage control

    (physiological decompensation)

    Neurological All unconscious trauma patients have brain injury until proven otherwise

    bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

    bull Avoid hypotension in brain injured patients= poor outcome

    bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

    bull Urgent CT and expert neurosurgical care is a must

    Questions

    Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

    Summary and Conclusionsbull It is truly all about the

    patient

    bull Team effort and framework is needed by design

    bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

    bull Trauma centers save lives

    • Welcome to Trauma Tracks
    • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
    • OBJECTIVES
    • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
    • Current Outcomes for CY 2009
    • FRAMEWORK
    • ProfileCredentials of a Trauma Patient
    • FrameworkReadiness hyper-vigilance-- produces effective outcomes
    • FrameworkConsistent organization and clear cut communication produces effective outcomes
    • Slide Number 10
    • Slide Number 11
    • Slide Number 12
    • Slide Number 13
    • Situation Awareness
    • Most Potentially Preventable Trauma Deaths are related to
    • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
    • Optimizing Resuscitation Across the Continuum
    • Airway All trauma patients need oxygen until proven otherwise
    • Airway All unstable trauma patients need a definitive airway
    • Prehospital Intubation
    • Prehospital Intubation
    • The impact of prehospital ventilation on outcome after severe traumatic brain injury
    • Bridge Devices 2010
    • Breathing All trauma patients need oxygen until proven otherwise
    • CT Scan for thoracic trauma
    • Hemorrhage All trauma patients are bleeding until proven otherwise
    • Hemorrhage PEARL
    • Hemorrhage 5 Anatomic Areas of Origin
    • Hemorrhage Importance of Lactate amp BD
    • Persistent Acidosis Indicates
    • Base Deficit Categories
    • Uses of Base Deficit in Trauma Care
    • Resuscitation End Points
    • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
    • Goal Directed Therapy PEARL
    • Optimizing Prehospital Resuscitation
    • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
    • PrehospitalTopicals 2010Hemostatic Field Dressing
    • Tourniquets 2010
    • Indications for Tourniquets
    • Intraosseous Infusion Devices 2010
    • Blood Substitutes 2010
    • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
    • Pelvic Binders 2010
    • Optimizing ED Trauma Resuscitation (cont)
    • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
    • Slide Number 47
    • Slide Number 48
    • ED Thoracotomy for Moribund Patients
    • Optimizing Resuscitation Across the Continuum
    • Damage ControlFocus on Physiology
    • Damage Control Patient Selection
    • Neurological All unconscious trauma patients have brain injury until proven otherwise
    • Questions
    • Summary and Conclusions

      OBJECTIVES

      bull At the end of this lecture the attendee will be able tondash Describe aspects of the nursing

      role in trauma resuscitation

      ndash Discuss assessment and management priorities that optimize trauma resuscitation

      ndash Geographical Service Area= 1 mill+ people 12 counties

      ndash 12000+ trauma admissions

      Average 65 trauma patients daily84 adults vs 16 peds70 male28 in (16-29 yr) old age group77 blunt trauma

      ndash 33 with ISS gt 15ndash 49 mortality rate

      Shands at UF Level I Trauma Center (Oct 1 2004 ndash December 31 2009)

      Source SUF Trauma Registry

      Green line represents equal distance between Shands at UF and other Level I Trauma Centers

      Current Outcomes for CY 2009

      bull Volume= 2578 patients

      bull 31 of patients with ISSgt15

      bull ICU LOS= 24 days

      bull Hospital LOS= 58 days ndash (92 index internal ACHA Methodology)

      bull 441 mortality rate overall (NTDB 48 1485098 pts)ndash (93 index internal ACHA Methodology)

      FRAMEWORKbull Readiness hyper-vigilance consistent

      organization and clear cut communication produces effective outcomes

      bull We should all know our A B C Dsbull Practice makes perfectbull The success of a trauma resuscitation is only

      as good as its team AND

      A proficient trauma team cannot function without a ldquowell-skilledrdquo trauma nurse

      ProfileCredentials of a Trauma Patient

      bull Risk taking behaviorndash Drinking distracted

      speed out for funhellipbull Male vs Female

      ndash 75 malebull Average age (young)

      ndash Mean age 17bull Mechanism frequently

      Blunt trauma and acutely episodic

      ProfileCredentials of a Trauma Nurse

      bull Assertive behaviorndash Autonomous focused

      passionatehellipbull Female vs Male

      ndash 75 femalebull Average age (wise)

      ndash Mean age 46bull Mechanism frequently

      Continuous care for trauma patients is chronically perpetual

      Framework Readiness hyper-vigilance-- produces effective outcomesbull Pre-established

      trauma system based on experience from military

      bull 2020 vision from a distance-- expect the unexpected

      ldquoRed-tailed hawkrdquo

      Framework Consistent organization and clear cut communication produces effective outcomes

      bull Well established and maintained clear roles and goals

      bull Similar training- street through hospital

      bull Effective function of the team begins with the Team leader

      RRT

      CC TechSr Resident

      Jr Resident

      EM Resident

      Medical Student(HampPOrders)

      Nurse 2(Scribe)

      AttendingTrauma

      Sr ResidentPGY5PGY4PGY3

      FAST

      Introducer-Subclavian

      A-line-Femoral Artery

      EM AttendingED ResidentAirway- edentulate tongue RSI

      Breathing- end tidal CO2 ambu NGOGPupils TMrsquos

      Suturing scalp lac (no staples)

      Nurse 1Change field IVs to warm IVs Second IV Manual BP Vital signs including core temp Warming measures

      Attaches monitors BP pulse oximetry EKG electrodes End tidal CO2

      Monitors amp reports physiologic parametersAssists with procedures as appropriate

      Prepares patient for transportObtains equipment supplies medications

      X-RaysCXR Pelvis

      JR ResidentVacutainer

      Femoral ArteryABGs

      Lactic AcidHgbHct

      BMPPTPTT-Elderly CHI ampAnticoagulantsBA- all drivers

      ETOH suspicionRectal Exam

      Foley Catheter

      Nurse 2 (Scribe)Documentation on Trauma Flow Sheet Ensures overall coordination of room Completes lab slips applies patient

      bracelet places phone calls for orders diagnostics admission

      RadiologyTech

      RRTAirway adjuncts

      SuctioningEnd tidal CO2

      Ambu

      FAST

      Nurse 1

      CC TechAttaches monitors BP pulse

      oximetry EKG electrodes End tidal

      CO2Performs CPR

      Assists with procedure set-upsObtains equipment and

      supplies

      Charge NurseAssists with coordination

      of patient care

      i-STAT AttendingEM

      New TowerNew Tower

      NurseNursersquorsquos Stations Station

      Trauma Resuscitation RoomTrauma Resuscitation Room

      Trauma Resuscitation RoomTrauma Resuscitation Room

      Trauma Center Trauma Center EntranceEntrance

      Main EntranceMain Entrance

      Alberta-- first trauma alert

      Situation Awareness

      Detection(Perception)

      Patient

      Team

      Environment

      Tools

      Diagnosis

      Prediction

      PremiseCause of instability must be

      recognized and corrected quickly by using a systematic approach

      It is important to identify and prioritize systemic compromise

      Most Potentially Preventable Trauma Deaths are related to

      bull Airway obstruction

      bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

      Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

      1 All trauma patients need oxygen until proven otherwise

      2 All trauma patients are bleeding until proven otherwise

      3 All trauma patients have a cervical spine injury until proven otherwise

      4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

      Optimizing Resuscitation Across the Continuum

      bull Prehospital Phasendash Key patient

      information must be communicated

      bull Mechanismbull GCSbull Vital Signsbull Interventions

      ndash Be familiar with modalities and controversies

      Pay attention to episodic events of hypotension

      Airway All trauma patients need oxygen until proven otherwise

      bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

      bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

      bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

      Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

      unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

      of breathingmaximizes O2 delivery

      ndash Corrects acid base disturbances

      ndash Allow clinician to focus on other life-threatening issues

      Prehospital Intubation

      bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

      bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

      Prehospital Intubation

      bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

      bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

      bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

      The impact of prehospital ventilation on outcome after severe traumatic brain injury

      Cusheri et al JTrauma 2007 Jun62(6)1330-6

      BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

      determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

      impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

      with lower mortality after severe TBI

      Bridge Devices 2010

      LMAKing Airway

      Combitube

      Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

      25 of all trauma deathsbull Understand the significance of

      patternsndash 1st and 2nd rib fxs abdominal breathing

      bull Treat the pneumo before ETTbull Life-threatening thoracic

      injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

      1

      2

      CT Scan for thoracic trauma

      An occult pneumothorax seen on a CT scan that was not detected on a plain

      anteroposterior supine chest radiograph

      bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

      bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

      Hemorrhage All trauma patients are bleeding until proven otherwise

      bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

      bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

      bull Prevent shock by arresting the bleeding

      bull Mandates the earliest possible ldquogoal directed therapyrdquo

      Hemorrhage PEARLbull Recognize trouble

      ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

      increases morbidity and doubles mortality especially in head injured patients

      bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

      ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

      Hemorrhage 5 Anatomic Areas of Origin

      Kirkpatrick AW et al Can J Surg 200851(1)57-69

      Hemorrhage Importance of Lactate amp BD

      bull For Resuscitation to Occurndash Adequate perfusion and

      ndash Tissue oxygenation must be restored

      bull Measures Directed atndash Enhancing O2 transport and O2 uptake

      ndash Controlling the bleeding

      Persistent Acidosis Indicates

      bull Continued bleeding

      bull Inadequate resuscitation

      bull Myocardial dysfunction

      dArr

      serum pH (735 ndash 745)uArr

      base deficit (2 to -2)uArr

      serum lactate (04 ndash 18)

      Base Deficit Categories

      bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

      A base deficit of -6 is a marker of severeinjury amp significant mortality

      Uses of Base Deficit in Trauma Care

      bull Excellent correlation of base deficit to lactate and pH

      bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

      bull Assessing shock and efficacy of resuscitation

      bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

      Resuscitation End Points

      bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

      ndash Mentation

      ndash UO

      ndash Labs base deficit serum lactate serum pH

      Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

      urine output remain standard of carebull Uncompensated shock requires additional

      resuscitationbull However after normalizing the above up to 85 of

      severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

      bull Better markers of adequate resuscitation are needed

      Goal Directed Therapy PEARLbull Recognize trouble

      ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

      ndash Anticoagulantsndash Beta blockers

      bull Early invasive monitoringbull Follow resuscitation goals

      Optimizing Prehospital Resuscitation

      bull Low volume fluid administration in penetrating injuries

      bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

      sheetsbinderbull Tourniquetsbull Scoop and run transports

      based on ldquogolden hourrdquo

      ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

      bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

      bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

      Optimizing ResuscitationOptimizing Resuscitation

      Prehospital Topicals 2010 Hemostatic Field Dressing

      bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

      bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

      Tourniquets 2010

      40

      Indications for Tourniquetsbull Stop bleeding when life-

      threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

      bull Stop bleeding with traumatic amputation

      Intraosseous Infusion Devices 2010

      EZ-IO

      FAST1

      Blood Substitutes 2010

      bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

      bull Ready for prime time ndash not yet but soon - maybe

      bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

      ndash JAMA - April 28 2008

      Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

      bull Direct pressure to all external bleeding

      bull Rapid suturing of all scalp and facial wounds

      bull Rapid application of ThomasHare Traction splints for femur fx

      bull Binder for pelvic fxbull Rapid reduction and pressure

      dressings of mangled extremities

      Pelvic Binders 2010

      Optimizing ED Trauma Resuscitation (cont)

      bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

      Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

      bull Use FAST to rapidly detect intra-abdominal fluid

      bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

      floor during chest tube insertion

      Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

      bull Intervene early in resuscitation to STOP bleeding

      bull Conserve blood earlybull Aggressive rapid and efficient operative

      interventionsbull Use novel methods to STOP bleeding in the

      operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

      coagulopathy

      bull Controversialndash Whether to administer type and how much

      bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

      Optimizing ED Trauma Resuscitation- Fluid Resuscitation

      MTP Process Shands at UF

      Attending Fellow Chief ResidentActing Chief Resident initiates MTP

      amp notifies designated RN

      Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

      refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

      Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

      runner to BB with cross amp match

      MTP runner delivers blood products to designated RN

      Ismore MTPneeded

      EDOR ICU

      Designated RN assures bloodadministered per MD order

      Designated RN assures blood administered per MD order

      Designated RN sends MTP runner for more blood

      MTP site

      Ispt to be

      transported withblood

      Designated RN transportsblood with pt to location(ORICU)

      END

      END

      END

      YES NO

      YES

      NO

      ED = Nurse ScribeOR = Circ RN notifies

      Charge Nurse

      62406

      ED Thoracotomy for Moribund Patients

      bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

      bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

      bull Aortic cross-clamping

      Optimizing Resuscitation Across the Continuum

      bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

      triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

      bullbull RegroupRegroup

      Damage Control Focus on Physiology

      bull Major paradigm shift in operative management of devastating injuries

      bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

      temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

      ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

      Damage Control Patient Selectionbull Instability

      bull Hypothermia (lt 34deg C)

      bull Coagulopathy

      bull Acidosis (pHlt 72BD -8)

      bull Major traumaAvoid ldquoground zero of damage control

      (physiological decompensation)

      Neurological All unconscious trauma patients have brain injury until proven otherwise

      bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

      bull Avoid hypotension in brain injured patients= poor outcome

      bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

      bull Urgent CT and expert neurosurgical care is a must

      Questions

      Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

      Summary and Conclusionsbull It is truly all about the

      patient

      bull Team effort and framework is needed by design

      bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

      bull Trauma centers save lives

      • Welcome to Trauma Tracks
      • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
      • OBJECTIVES
      • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
      • Current Outcomes for CY 2009
      • FRAMEWORK
      • ProfileCredentials of a Trauma Patient
      • FrameworkReadiness hyper-vigilance-- produces effective outcomes
      • FrameworkConsistent organization and clear cut communication produces effective outcomes
      • Slide Number 10
      • Slide Number 11
      • Slide Number 12
      • Slide Number 13
      • Situation Awareness
      • Most Potentially Preventable Trauma Deaths are related to
      • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
      • Optimizing Resuscitation Across the Continuum
      • Airway All trauma patients need oxygen until proven otherwise
      • Airway All unstable trauma patients need a definitive airway
      • Prehospital Intubation
      • Prehospital Intubation
      • The impact of prehospital ventilation on outcome after severe traumatic brain injury
      • Bridge Devices 2010
      • Breathing All trauma patients need oxygen until proven otherwise
      • CT Scan for thoracic trauma
      • Hemorrhage All trauma patients are bleeding until proven otherwise
      • Hemorrhage PEARL
      • Hemorrhage 5 Anatomic Areas of Origin
      • Hemorrhage Importance of Lactate amp BD
      • Persistent Acidosis Indicates
      • Base Deficit Categories
      • Uses of Base Deficit in Trauma Care
      • Resuscitation End Points
      • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
      • Goal Directed Therapy PEARL
      • Optimizing Prehospital Resuscitation
      • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
      • PrehospitalTopicals 2010Hemostatic Field Dressing
      • Tourniquets 2010
      • Indications for Tourniquets
      • Intraosseous Infusion Devices 2010
      • Blood Substitutes 2010
      • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
      • Pelvic Binders 2010
      • Optimizing ED Trauma Resuscitation (cont)
      • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
      • Slide Number 47
      • Slide Number 48
      • ED Thoracotomy for Moribund Patients
      • Optimizing Resuscitation Across the Continuum
      • Damage ControlFocus on Physiology
      • Damage Control Patient Selection
      • Neurological All unconscious trauma patients have brain injury until proven otherwise
      • Questions
      • Summary and Conclusions

        ndash Geographical Service Area= 1 mill+ people 12 counties

        ndash 12000+ trauma admissions

        Average 65 trauma patients daily84 adults vs 16 peds70 male28 in (16-29 yr) old age group77 blunt trauma

        ndash 33 with ISS gt 15ndash 49 mortality rate

        Shands at UF Level I Trauma Center (Oct 1 2004 ndash December 31 2009)

        Source SUF Trauma Registry

        Green line represents equal distance between Shands at UF and other Level I Trauma Centers

        Current Outcomes for CY 2009

        bull Volume= 2578 patients

        bull 31 of patients with ISSgt15

        bull ICU LOS= 24 days

        bull Hospital LOS= 58 days ndash (92 index internal ACHA Methodology)

        bull 441 mortality rate overall (NTDB 48 1485098 pts)ndash (93 index internal ACHA Methodology)

        FRAMEWORKbull Readiness hyper-vigilance consistent

        organization and clear cut communication produces effective outcomes

        bull We should all know our A B C Dsbull Practice makes perfectbull The success of a trauma resuscitation is only

        as good as its team AND

        A proficient trauma team cannot function without a ldquowell-skilledrdquo trauma nurse

        ProfileCredentials of a Trauma Patient

        bull Risk taking behaviorndash Drinking distracted

        speed out for funhellipbull Male vs Female

        ndash 75 malebull Average age (young)

        ndash Mean age 17bull Mechanism frequently

        Blunt trauma and acutely episodic

        ProfileCredentials of a Trauma Nurse

        bull Assertive behaviorndash Autonomous focused

        passionatehellipbull Female vs Male

        ndash 75 femalebull Average age (wise)

        ndash Mean age 46bull Mechanism frequently

        Continuous care for trauma patients is chronically perpetual

        Framework Readiness hyper-vigilance-- produces effective outcomesbull Pre-established

        trauma system based on experience from military

        bull 2020 vision from a distance-- expect the unexpected

        ldquoRed-tailed hawkrdquo

        Framework Consistent organization and clear cut communication produces effective outcomes

        bull Well established and maintained clear roles and goals

        bull Similar training- street through hospital

        bull Effective function of the team begins with the Team leader

        RRT

        CC TechSr Resident

        Jr Resident

        EM Resident

        Medical Student(HampPOrders)

        Nurse 2(Scribe)

        AttendingTrauma

        Sr ResidentPGY5PGY4PGY3

        FAST

        Introducer-Subclavian

        A-line-Femoral Artery

        EM AttendingED ResidentAirway- edentulate tongue RSI

        Breathing- end tidal CO2 ambu NGOGPupils TMrsquos

        Suturing scalp lac (no staples)

        Nurse 1Change field IVs to warm IVs Second IV Manual BP Vital signs including core temp Warming measures

        Attaches monitors BP pulse oximetry EKG electrodes End tidal CO2

        Monitors amp reports physiologic parametersAssists with procedures as appropriate

        Prepares patient for transportObtains equipment supplies medications

        X-RaysCXR Pelvis

        JR ResidentVacutainer

        Femoral ArteryABGs

        Lactic AcidHgbHct

        BMPPTPTT-Elderly CHI ampAnticoagulantsBA- all drivers

        ETOH suspicionRectal Exam

        Foley Catheter

        Nurse 2 (Scribe)Documentation on Trauma Flow Sheet Ensures overall coordination of room Completes lab slips applies patient

        bracelet places phone calls for orders diagnostics admission

        RadiologyTech

        RRTAirway adjuncts

        SuctioningEnd tidal CO2

        Ambu

        FAST

        Nurse 1

        CC TechAttaches monitors BP pulse

        oximetry EKG electrodes End tidal

        CO2Performs CPR

        Assists with procedure set-upsObtains equipment and

        supplies

        Charge NurseAssists with coordination

        of patient care

        i-STAT AttendingEM

        New TowerNew Tower

        NurseNursersquorsquos Stations Station

        Trauma Resuscitation RoomTrauma Resuscitation Room

        Trauma Resuscitation RoomTrauma Resuscitation Room

        Trauma Center Trauma Center EntranceEntrance

        Main EntranceMain Entrance

        Alberta-- first trauma alert

        Situation Awareness

        Detection(Perception)

        Patient

        Team

        Environment

        Tools

        Diagnosis

        Prediction

        PremiseCause of instability must be

        recognized and corrected quickly by using a systematic approach

        It is important to identify and prioritize systemic compromise

        Most Potentially Preventable Trauma Deaths are related to

        bull Airway obstruction

        bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

        Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

        1 All trauma patients need oxygen until proven otherwise

        2 All trauma patients are bleeding until proven otherwise

        3 All trauma patients have a cervical spine injury until proven otherwise

        4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

        Optimizing Resuscitation Across the Continuum

        bull Prehospital Phasendash Key patient

        information must be communicated

        bull Mechanismbull GCSbull Vital Signsbull Interventions

        ndash Be familiar with modalities and controversies

        Pay attention to episodic events of hypotension

        Airway All trauma patients need oxygen until proven otherwise

        bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

        bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

        bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

        Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

        unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

        of breathingmaximizes O2 delivery

        ndash Corrects acid base disturbances

        ndash Allow clinician to focus on other life-threatening issues

        Prehospital Intubation

        bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

        bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

        Prehospital Intubation

        bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

        bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

        bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

        The impact of prehospital ventilation on outcome after severe traumatic brain injury

        Cusheri et al JTrauma 2007 Jun62(6)1330-6

        BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

        determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

        impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

        with lower mortality after severe TBI

        Bridge Devices 2010

        LMAKing Airway

        Combitube

        Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

        25 of all trauma deathsbull Understand the significance of

        patternsndash 1st and 2nd rib fxs abdominal breathing

        bull Treat the pneumo before ETTbull Life-threatening thoracic

        injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

        1

        2

        CT Scan for thoracic trauma

        An occult pneumothorax seen on a CT scan that was not detected on a plain

        anteroposterior supine chest radiograph

        bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

        bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

        Hemorrhage All trauma patients are bleeding until proven otherwise

        bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

        bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

        bull Prevent shock by arresting the bleeding

        bull Mandates the earliest possible ldquogoal directed therapyrdquo

        Hemorrhage PEARLbull Recognize trouble

        ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

        increases morbidity and doubles mortality especially in head injured patients

        bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

        ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

        Hemorrhage 5 Anatomic Areas of Origin

        Kirkpatrick AW et al Can J Surg 200851(1)57-69

        Hemorrhage Importance of Lactate amp BD

        bull For Resuscitation to Occurndash Adequate perfusion and

        ndash Tissue oxygenation must be restored

        bull Measures Directed atndash Enhancing O2 transport and O2 uptake

        ndash Controlling the bleeding

        Persistent Acidosis Indicates

        bull Continued bleeding

        bull Inadequate resuscitation

        bull Myocardial dysfunction

        dArr

        serum pH (735 ndash 745)uArr

        base deficit (2 to -2)uArr

        serum lactate (04 ndash 18)

        Base Deficit Categories

        bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

        A base deficit of -6 is a marker of severeinjury amp significant mortality

        Uses of Base Deficit in Trauma Care

        bull Excellent correlation of base deficit to lactate and pH

        bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

        bull Assessing shock and efficacy of resuscitation

        bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

        Resuscitation End Points

        bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

        ndash Mentation

        ndash UO

        ndash Labs base deficit serum lactate serum pH

        Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

        urine output remain standard of carebull Uncompensated shock requires additional

        resuscitationbull However after normalizing the above up to 85 of

        severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

        bull Better markers of adequate resuscitation are needed

        Goal Directed Therapy PEARLbull Recognize trouble

        ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

        ndash Anticoagulantsndash Beta blockers

        bull Early invasive monitoringbull Follow resuscitation goals

        Optimizing Prehospital Resuscitation

        bull Low volume fluid administration in penetrating injuries

        bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

        sheetsbinderbull Tourniquetsbull Scoop and run transports

        based on ldquogolden hourrdquo

        ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

        bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

        bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

        Optimizing ResuscitationOptimizing Resuscitation

        Prehospital Topicals 2010 Hemostatic Field Dressing

        bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

        bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

        Tourniquets 2010

        40

        Indications for Tourniquetsbull Stop bleeding when life-

        threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

        bull Stop bleeding with traumatic amputation

        Intraosseous Infusion Devices 2010

        EZ-IO

        FAST1

        Blood Substitutes 2010

        bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

        bull Ready for prime time ndash not yet but soon - maybe

        bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

        ndash JAMA - April 28 2008

        Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

        bull Direct pressure to all external bleeding

        bull Rapid suturing of all scalp and facial wounds

        bull Rapid application of ThomasHare Traction splints for femur fx

        bull Binder for pelvic fxbull Rapid reduction and pressure

        dressings of mangled extremities

        Pelvic Binders 2010

        Optimizing ED Trauma Resuscitation (cont)

        bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

        Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

        bull Use FAST to rapidly detect intra-abdominal fluid

        bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

        floor during chest tube insertion

        Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

        bull Intervene early in resuscitation to STOP bleeding

        bull Conserve blood earlybull Aggressive rapid and efficient operative

        interventionsbull Use novel methods to STOP bleeding in the

        operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

        coagulopathy

        bull Controversialndash Whether to administer type and how much

        bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

        Optimizing ED Trauma Resuscitation- Fluid Resuscitation

        MTP Process Shands at UF

        Attending Fellow Chief ResidentActing Chief Resident initiates MTP

        amp notifies designated RN

        Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

        refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

        Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

        runner to BB with cross amp match

        MTP runner delivers blood products to designated RN

        Ismore MTPneeded

        EDOR ICU

        Designated RN assures bloodadministered per MD order

        Designated RN assures blood administered per MD order

        Designated RN sends MTP runner for more blood

        MTP site

        Ispt to be

        transported withblood

        Designated RN transportsblood with pt to location(ORICU)

        END

        END

        END

        YES NO

        YES

        NO

        ED = Nurse ScribeOR = Circ RN notifies

        Charge Nurse

        62406

        ED Thoracotomy for Moribund Patients

        bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

        bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

        bull Aortic cross-clamping

        Optimizing Resuscitation Across the Continuum

        bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

        triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

        bullbull RegroupRegroup

        Damage Control Focus on Physiology

        bull Major paradigm shift in operative management of devastating injuries

        bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

        temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

        ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

        Damage Control Patient Selectionbull Instability

        bull Hypothermia (lt 34deg C)

        bull Coagulopathy

        bull Acidosis (pHlt 72BD -8)

        bull Major traumaAvoid ldquoground zero of damage control

        (physiological decompensation)

        Neurological All unconscious trauma patients have brain injury until proven otherwise

        bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

        bull Avoid hypotension in brain injured patients= poor outcome

        bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

        bull Urgent CT and expert neurosurgical care is a must

        Questions

        Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

        Summary and Conclusionsbull It is truly all about the

        patient

        bull Team effort and framework is needed by design

        bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

        bull Trauma centers save lives

        • Welcome to Trauma Tracks
        • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
        • OBJECTIVES
        • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
        • Current Outcomes for CY 2009
        • FRAMEWORK
        • ProfileCredentials of a Trauma Patient
        • FrameworkReadiness hyper-vigilance-- produces effective outcomes
        • FrameworkConsistent organization and clear cut communication produces effective outcomes
        • Slide Number 10
        • Slide Number 11
        • Slide Number 12
        • Slide Number 13
        • Situation Awareness
        • Most Potentially Preventable Trauma Deaths are related to
        • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
        • Optimizing Resuscitation Across the Continuum
        • Airway All trauma patients need oxygen until proven otherwise
        • Airway All unstable trauma patients need a definitive airway
        • Prehospital Intubation
        • Prehospital Intubation
        • The impact of prehospital ventilation on outcome after severe traumatic brain injury
        • Bridge Devices 2010
        • Breathing All trauma patients need oxygen until proven otherwise
        • CT Scan for thoracic trauma
        • Hemorrhage All trauma patients are bleeding until proven otherwise
        • Hemorrhage PEARL
        • Hemorrhage 5 Anatomic Areas of Origin
        • Hemorrhage Importance of Lactate amp BD
        • Persistent Acidosis Indicates
        • Base Deficit Categories
        • Uses of Base Deficit in Trauma Care
        • Resuscitation End Points
        • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
        • Goal Directed Therapy PEARL
        • Optimizing Prehospital Resuscitation
        • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
        • PrehospitalTopicals 2010Hemostatic Field Dressing
        • Tourniquets 2010
        • Indications for Tourniquets
        • Intraosseous Infusion Devices 2010
        • Blood Substitutes 2010
        • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
        • Pelvic Binders 2010
        • Optimizing ED Trauma Resuscitation (cont)
        • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
        • Slide Number 47
        • Slide Number 48
        • ED Thoracotomy for Moribund Patients
        • Optimizing Resuscitation Across the Continuum
        • Damage ControlFocus on Physiology
        • Damage Control Patient Selection
        • Neurological All unconscious trauma patients have brain injury until proven otherwise
        • Questions
        • Summary and Conclusions

          Current Outcomes for CY 2009

          bull Volume= 2578 patients

          bull 31 of patients with ISSgt15

          bull ICU LOS= 24 days

          bull Hospital LOS= 58 days ndash (92 index internal ACHA Methodology)

          bull 441 mortality rate overall (NTDB 48 1485098 pts)ndash (93 index internal ACHA Methodology)

          FRAMEWORKbull Readiness hyper-vigilance consistent

          organization and clear cut communication produces effective outcomes

          bull We should all know our A B C Dsbull Practice makes perfectbull The success of a trauma resuscitation is only

          as good as its team AND

          A proficient trauma team cannot function without a ldquowell-skilledrdquo trauma nurse

          ProfileCredentials of a Trauma Patient

          bull Risk taking behaviorndash Drinking distracted

          speed out for funhellipbull Male vs Female

          ndash 75 malebull Average age (young)

          ndash Mean age 17bull Mechanism frequently

          Blunt trauma and acutely episodic

          ProfileCredentials of a Trauma Nurse

          bull Assertive behaviorndash Autonomous focused

          passionatehellipbull Female vs Male

          ndash 75 femalebull Average age (wise)

          ndash Mean age 46bull Mechanism frequently

          Continuous care for trauma patients is chronically perpetual

          Framework Readiness hyper-vigilance-- produces effective outcomesbull Pre-established

          trauma system based on experience from military

          bull 2020 vision from a distance-- expect the unexpected

          ldquoRed-tailed hawkrdquo

          Framework Consistent organization and clear cut communication produces effective outcomes

          bull Well established and maintained clear roles and goals

          bull Similar training- street through hospital

          bull Effective function of the team begins with the Team leader

          RRT

          CC TechSr Resident

          Jr Resident

          EM Resident

          Medical Student(HampPOrders)

          Nurse 2(Scribe)

          AttendingTrauma

          Sr ResidentPGY5PGY4PGY3

          FAST

          Introducer-Subclavian

          A-line-Femoral Artery

          EM AttendingED ResidentAirway- edentulate tongue RSI

          Breathing- end tidal CO2 ambu NGOGPupils TMrsquos

          Suturing scalp lac (no staples)

          Nurse 1Change field IVs to warm IVs Second IV Manual BP Vital signs including core temp Warming measures

          Attaches monitors BP pulse oximetry EKG electrodes End tidal CO2

          Monitors amp reports physiologic parametersAssists with procedures as appropriate

          Prepares patient for transportObtains equipment supplies medications

          X-RaysCXR Pelvis

          JR ResidentVacutainer

          Femoral ArteryABGs

          Lactic AcidHgbHct

          BMPPTPTT-Elderly CHI ampAnticoagulantsBA- all drivers

          ETOH suspicionRectal Exam

          Foley Catheter

          Nurse 2 (Scribe)Documentation on Trauma Flow Sheet Ensures overall coordination of room Completes lab slips applies patient

          bracelet places phone calls for orders diagnostics admission

          RadiologyTech

          RRTAirway adjuncts

          SuctioningEnd tidal CO2

          Ambu

          FAST

          Nurse 1

          CC TechAttaches monitors BP pulse

          oximetry EKG electrodes End tidal

          CO2Performs CPR

          Assists with procedure set-upsObtains equipment and

          supplies

          Charge NurseAssists with coordination

          of patient care

          i-STAT AttendingEM

          New TowerNew Tower

          NurseNursersquorsquos Stations Station

          Trauma Resuscitation RoomTrauma Resuscitation Room

          Trauma Resuscitation RoomTrauma Resuscitation Room

          Trauma Center Trauma Center EntranceEntrance

          Main EntranceMain Entrance

          Alberta-- first trauma alert

          Situation Awareness

          Detection(Perception)

          Patient

          Team

          Environment

          Tools

          Diagnosis

          Prediction

          PremiseCause of instability must be

          recognized and corrected quickly by using a systematic approach

          It is important to identify and prioritize systemic compromise

          Most Potentially Preventable Trauma Deaths are related to

          bull Airway obstruction

          bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

          Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

          1 All trauma patients need oxygen until proven otherwise

          2 All trauma patients are bleeding until proven otherwise

          3 All trauma patients have a cervical spine injury until proven otherwise

          4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

          Optimizing Resuscitation Across the Continuum

          bull Prehospital Phasendash Key patient

          information must be communicated

          bull Mechanismbull GCSbull Vital Signsbull Interventions

          ndash Be familiar with modalities and controversies

          Pay attention to episodic events of hypotension

          Airway All trauma patients need oxygen until proven otherwise

          bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

          bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

          bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

          Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

          unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

          of breathingmaximizes O2 delivery

          ndash Corrects acid base disturbances

          ndash Allow clinician to focus on other life-threatening issues

          Prehospital Intubation

          bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

          bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

          Prehospital Intubation

          bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

          bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

          bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

          The impact of prehospital ventilation on outcome after severe traumatic brain injury

          Cusheri et al JTrauma 2007 Jun62(6)1330-6

          BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

          determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

          impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

          with lower mortality after severe TBI

          Bridge Devices 2010

          LMAKing Airway

          Combitube

          Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

          25 of all trauma deathsbull Understand the significance of

          patternsndash 1st and 2nd rib fxs abdominal breathing

          bull Treat the pneumo before ETTbull Life-threatening thoracic

          injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

          1

          2

          CT Scan for thoracic trauma

          An occult pneumothorax seen on a CT scan that was not detected on a plain

          anteroposterior supine chest radiograph

          bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

          bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

          Hemorrhage All trauma patients are bleeding until proven otherwise

          bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

          bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

          bull Prevent shock by arresting the bleeding

          bull Mandates the earliest possible ldquogoal directed therapyrdquo

          Hemorrhage PEARLbull Recognize trouble

          ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

          increases morbidity and doubles mortality especially in head injured patients

          bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

          ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

          Hemorrhage 5 Anatomic Areas of Origin

          Kirkpatrick AW et al Can J Surg 200851(1)57-69

          Hemorrhage Importance of Lactate amp BD

          bull For Resuscitation to Occurndash Adequate perfusion and

          ndash Tissue oxygenation must be restored

          bull Measures Directed atndash Enhancing O2 transport and O2 uptake

          ndash Controlling the bleeding

          Persistent Acidosis Indicates

          bull Continued bleeding

          bull Inadequate resuscitation

          bull Myocardial dysfunction

          dArr

          serum pH (735 ndash 745)uArr

          base deficit (2 to -2)uArr

          serum lactate (04 ndash 18)

          Base Deficit Categories

          bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

          A base deficit of -6 is a marker of severeinjury amp significant mortality

          Uses of Base Deficit in Trauma Care

          bull Excellent correlation of base deficit to lactate and pH

          bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

          bull Assessing shock and efficacy of resuscitation

          bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

          Resuscitation End Points

          bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

          ndash Mentation

          ndash UO

          ndash Labs base deficit serum lactate serum pH

          Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

          urine output remain standard of carebull Uncompensated shock requires additional

          resuscitationbull However after normalizing the above up to 85 of

          severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

          bull Better markers of adequate resuscitation are needed

          Goal Directed Therapy PEARLbull Recognize trouble

          ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

          ndash Anticoagulantsndash Beta blockers

          bull Early invasive monitoringbull Follow resuscitation goals

          Optimizing Prehospital Resuscitation

          bull Low volume fluid administration in penetrating injuries

          bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

          sheetsbinderbull Tourniquetsbull Scoop and run transports

          based on ldquogolden hourrdquo

          ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

          bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

          bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

          Optimizing ResuscitationOptimizing Resuscitation

          Prehospital Topicals 2010 Hemostatic Field Dressing

          bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

          bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

          Tourniquets 2010

          40

          Indications for Tourniquetsbull Stop bleeding when life-

          threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

          bull Stop bleeding with traumatic amputation

          Intraosseous Infusion Devices 2010

          EZ-IO

          FAST1

          Blood Substitutes 2010

          bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

          bull Ready for prime time ndash not yet but soon - maybe

          bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

          ndash JAMA - April 28 2008

          Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

          bull Direct pressure to all external bleeding

          bull Rapid suturing of all scalp and facial wounds

          bull Rapid application of ThomasHare Traction splints for femur fx

          bull Binder for pelvic fxbull Rapid reduction and pressure

          dressings of mangled extremities

          Pelvic Binders 2010

          Optimizing ED Trauma Resuscitation (cont)

          bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

          Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

          bull Use FAST to rapidly detect intra-abdominal fluid

          bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

          floor during chest tube insertion

          Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

          bull Intervene early in resuscitation to STOP bleeding

          bull Conserve blood earlybull Aggressive rapid and efficient operative

          interventionsbull Use novel methods to STOP bleeding in the

          operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

          coagulopathy

          bull Controversialndash Whether to administer type and how much

          bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

          Optimizing ED Trauma Resuscitation- Fluid Resuscitation

          MTP Process Shands at UF

          Attending Fellow Chief ResidentActing Chief Resident initiates MTP

          amp notifies designated RN

          Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

          refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

          Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

          runner to BB with cross amp match

          MTP runner delivers blood products to designated RN

          Ismore MTPneeded

          EDOR ICU

          Designated RN assures bloodadministered per MD order

          Designated RN assures blood administered per MD order

          Designated RN sends MTP runner for more blood

          MTP site

          Ispt to be

          transported withblood

          Designated RN transportsblood with pt to location(ORICU)

          END

          END

          END

          YES NO

          YES

          NO

          ED = Nurse ScribeOR = Circ RN notifies

          Charge Nurse

          62406

          ED Thoracotomy for Moribund Patients

          bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

          bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

          bull Aortic cross-clamping

          Optimizing Resuscitation Across the Continuum

          bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

          triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

          bullbull RegroupRegroup

          Damage Control Focus on Physiology

          bull Major paradigm shift in operative management of devastating injuries

          bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

          temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

          ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

          Damage Control Patient Selectionbull Instability

          bull Hypothermia (lt 34deg C)

          bull Coagulopathy

          bull Acidosis (pHlt 72BD -8)

          bull Major traumaAvoid ldquoground zero of damage control

          (physiological decompensation)

          Neurological All unconscious trauma patients have brain injury until proven otherwise

          bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

          bull Avoid hypotension in brain injured patients= poor outcome

          bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

          bull Urgent CT and expert neurosurgical care is a must

          Questions

          Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

          Summary and Conclusionsbull It is truly all about the

          patient

          bull Team effort and framework is needed by design

          bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

          bull Trauma centers save lives

          • Welcome to Trauma Tracks
          • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
          • OBJECTIVES
          • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
          • Current Outcomes for CY 2009
          • FRAMEWORK
          • ProfileCredentials of a Trauma Patient
          • FrameworkReadiness hyper-vigilance-- produces effective outcomes
          • FrameworkConsistent organization and clear cut communication produces effective outcomes
          • Slide Number 10
          • Slide Number 11
          • Slide Number 12
          • Slide Number 13
          • Situation Awareness
          • Most Potentially Preventable Trauma Deaths are related to
          • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
          • Optimizing Resuscitation Across the Continuum
          • Airway All trauma patients need oxygen until proven otherwise
          • Airway All unstable trauma patients need a definitive airway
          • Prehospital Intubation
          • Prehospital Intubation
          • The impact of prehospital ventilation on outcome after severe traumatic brain injury
          • Bridge Devices 2010
          • Breathing All trauma patients need oxygen until proven otherwise
          • CT Scan for thoracic trauma
          • Hemorrhage All trauma patients are bleeding until proven otherwise
          • Hemorrhage PEARL
          • Hemorrhage 5 Anatomic Areas of Origin
          • Hemorrhage Importance of Lactate amp BD
          • Persistent Acidosis Indicates
          • Base Deficit Categories
          • Uses of Base Deficit in Trauma Care
          • Resuscitation End Points
          • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
          • Goal Directed Therapy PEARL
          • Optimizing Prehospital Resuscitation
          • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
          • PrehospitalTopicals 2010Hemostatic Field Dressing
          • Tourniquets 2010
          • Indications for Tourniquets
          • Intraosseous Infusion Devices 2010
          • Blood Substitutes 2010
          • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
          • Pelvic Binders 2010
          • Optimizing ED Trauma Resuscitation (cont)
          • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
          • Slide Number 47
          • Slide Number 48
          • ED Thoracotomy for Moribund Patients
          • Optimizing Resuscitation Across the Continuum
          • Damage ControlFocus on Physiology
          • Damage Control Patient Selection
          • Neurological All unconscious trauma patients have brain injury until proven otherwise
          • Questions
          • Summary and Conclusions

            FRAMEWORKbull Readiness hyper-vigilance consistent

            organization and clear cut communication produces effective outcomes

            bull We should all know our A B C Dsbull Practice makes perfectbull The success of a trauma resuscitation is only

            as good as its team AND

            A proficient trauma team cannot function without a ldquowell-skilledrdquo trauma nurse

            ProfileCredentials of a Trauma Patient

            bull Risk taking behaviorndash Drinking distracted

            speed out for funhellipbull Male vs Female

            ndash 75 malebull Average age (young)

            ndash Mean age 17bull Mechanism frequently

            Blunt trauma and acutely episodic

            ProfileCredentials of a Trauma Nurse

            bull Assertive behaviorndash Autonomous focused

            passionatehellipbull Female vs Male

            ndash 75 femalebull Average age (wise)

            ndash Mean age 46bull Mechanism frequently

            Continuous care for trauma patients is chronically perpetual

            Framework Readiness hyper-vigilance-- produces effective outcomesbull Pre-established

            trauma system based on experience from military

            bull 2020 vision from a distance-- expect the unexpected

            ldquoRed-tailed hawkrdquo

            Framework Consistent organization and clear cut communication produces effective outcomes

            bull Well established and maintained clear roles and goals

            bull Similar training- street through hospital

            bull Effective function of the team begins with the Team leader

            RRT

            CC TechSr Resident

            Jr Resident

            EM Resident

            Medical Student(HampPOrders)

            Nurse 2(Scribe)

            AttendingTrauma

            Sr ResidentPGY5PGY4PGY3

            FAST

            Introducer-Subclavian

            A-line-Femoral Artery

            EM AttendingED ResidentAirway- edentulate tongue RSI

            Breathing- end tidal CO2 ambu NGOGPupils TMrsquos

            Suturing scalp lac (no staples)

            Nurse 1Change field IVs to warm IVs Second IV Manual BP Vital signs including core temp Warming measures

            Attaches monitors BP pulse oximetry EKG electrodes End tidal CO2

            Monitors amp reports physiologic parametersAssists with procedures as appropriate

            Prepares patient for transportObtains equipment supplies medications

            X-RaysCXR Pelvis

            JR ResidentVacutainer

            Femoral ArteryABGs

            Lactic AcidHgbHct

            BMPPTPTT-Elderly CHI ampAnticoagulantsBA- all drivers

            ETOH suspicionRectal Exam

            Foley Catheter

            Nurse 2 (Scribe)Documentation on Trauma Flow Sheet Ensures overall coordination of room Completes lab slips applies patient

            bracelet places phone calls for orders diagnostics admission

            RadiologyTech

            RRTAirway adjuncts

            SuctioningEnd tidal CO2

            Ambu

            FAST

            Nurse 1

            CC TechAttaches monitors BP pulse

            oximetry EKG electrodes End tidal

            CO2Performs CPR

            Assists with procedure set-upsObtains equipment and

            supplies

            Charge NurseAssists with coordination

            of patient care

            i-STAT AttendingEM

            New TowerNew Tower

            NurseNursersquorsquos Stations Station

            Trauma Resuscitation RoomTrauma Resuscitation Room

            Trauma Resuscitation RoomTrauma Resuscitation Room

            Trauma Center Trauma Center EntranceEntrance

            Main EntranceMain Entrance

            Alberta-- first trauma alert

            Situation Awareness

            Detection(Perception)

            Patient

            Team

            Environment

            Tools

            Diagnosis

            Prediction

            PremiseCause of instability must be

            recognized and corrected quickly by using a systematic approach

            It is important to identify and prioritize systemic compromise

            Most Potentially Preventable Trauma Deaths are related to

            bull Airway obstruction

            bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

            Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

            1 All trauma patients need oxygen until proven otherwise

            2 All trauma patients are bleeding until proven otherwise

            3 All trauma patients have a cervical spine injury until proven otherwise

            4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

            Optimizing Resuscitation Across the Continuum

            bull Prehospital Phasendash Key patient

            information must be communicated

            bull Mechanismbull GCSbull Vital Signsbull Interventions

            ndash Be familiar with modalities and controversies

            Pay attention to episodic events of hypotension

            Airway All trauma patients need oxygen until proven otherwise

            bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

            bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

            bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

            Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

            unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

            of breathingmaximizes O2 delivery

            ndash Corrects acid base disturbances

            ndash Allow clinician to focus on other life-threatening issues

            Prehospital Intubation

            bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

            bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

            Prehospital Intubation

            bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

            bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

            bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

            The impact of prehospital ventilation on outcome after severe traumatic brain injury

            Cusheri et al JTrauma 2007 Jun62(6)1330-6

            BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

            determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

            impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

            with lower mortality after severe TBI

            Bridge Devices 2010

            LMAKing Airway

            Combitube

            Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

            25 of all trauma deathsbull Understand the significance of

            patternsndash 1st and 2nd rib fxs abdominal breathing

            bull Treat the pneumo before ETTbull Life-threatening thoracic

            injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

            1

            2

            CT Scan for thoracic trauma

            An occult pneumothorax seen on a CT scan that was not detected on a plain

            anteroposterior supine chest radiograph

            bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

            bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

            Hemorrhage All trauma patients are bleeding until proven otherwise

            bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

            bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

            bull Prevent shock by arresting the bleeding

            bull Mandates the earliest possible ldquogoal directed therapyrdquo

            Hemorrhage PEARLbull Recognize trouble

            ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

            increases morbidity and doubles mortality especially in head injured patients

            bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

            ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

            Hemorrhage 5 Anatomic Areas of Origin

            Kirkpatrick AW et al Can J Surg 200851(1)57-69

            Hemorrhage Importance of Lactate amp BD

            bull For Resuscitation to Occurndash Adequate perfusion and

            ndash Tissue oxygenation must be restored

            bull Measures Directed atndash Enhancing O2 transport and O2 uptake

            ndash Controlling the bleeding

            Persistent Acidosis Indicates

            bull Continued bleeding

            bull Inadequate resuscitation

            bull Myocardial dysfunction

            dArr

            serum pH (735 ndash 745)uArr

            base deficit (2 to -2)uArr

            serum lactate (04 ndash 18)

            Base Deficit Categories

            bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

            A base deficit of -6 is a marker of severeinjury amp significant mortality

            Uses of Base Deficit in Trauma Care

            bull Excellent correlation of base deficit to lactate and pH

            bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

            bull Assessing shock and efficacy of resuscitation

            bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

            Resuscitation End Points

            bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

            ndash Mentation

            ndash UO

            ndash Labs base deficit serum lactate serum pH

            Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

            urine output remain standard of carebull Uncompensated shock requires additional

            resuscitationbull However after normalizing the above up to 85 of

            severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

            bull Better markers of adequate resuscitation are needed

            Goal Directed Therapy PEARLbull Recognize trouble

            ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

            ndash Anticoagulantsndash Beta blockers

            bull Early invasive monitoringbull Follow resuscitation goals

            Optimizing Prehospital Resuscitation

            bull Low volume fluid administration in penetrating injuries

            bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

            sheetsbinderbull Tourniquetsbull Scoop and run transports

            based on ldquogolden hourrdquo

            ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

            bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

            bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

            Optimizing ResuscitationOptimizing Resuscitation

            Prehospital Topicals 2010 Hemostatic Field Dressing

            bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

            bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

            Tourniquets 2010

            40

            Indications for Tourniquetsbull Stop bleeding when life-

            threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

            bull Stop bleeding with traumatic amputation

            Intraosseous Infusion Devices 2010

            EZ-IO

            FAST1

            Blood Substitutes 2010

            bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

            bull Ready for prime time ndash not yet but soon - maybe

            bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

            ndash JAMA - April 28 2008

            Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

            bull Direct pressure to all external bleeding

            bull Rapid suturing of all scalp and facial wounds

            bull Rapid application of ThomasHare Traction splints for femur fx

            bull Binder for pelvic fxbull Rapid reduction and pressure

            dressings of mangled extremities

            Pelvic Binders 2010

            Optimizing ED Trauma Resuscitation (cont)

            bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

            Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

            bull Use FAST to rapidly detect intra-abdominal fluid

            bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

            floor during chest tube insertion

            Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

            bull Intervene early in resuscitation to STOP bleeding

            bull Conserve blood earlybull Aggressive rapid and efficient operative

            interventionsbull Use novel methods to STOP bleeding in the

            operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

            coagulopathy

            bull Controversialndash Whether to administer type and how much

            bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

            Optimizing ED Trauma Resuscitation- Fluid Resuscitation

            MTP Process Shands at UF

            Attending Fellow Chief ResidentActing Chief Resident initiates MTP

            amp notifies designated RN

            Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

            refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

            Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

            runner to BB with cross amp match

            MTP runner delivers blood products to designated RN

            Ismore MTPneeded

            EDOR ICU

            Designated RN assures bloodadministered per MD order

            Designated RN assures blood administered per MD order

            Designated RN sends MTP runner for more blood

            MTP site

            Ispt to be

            transported withblood

            Designated RN transportsblood with pt to location(ORICU)

            END

            END

            END

            YES NO

            YES

            NO

            ED = Nurse ScribeOR = Circ RN notifies

            Charge Nurse

            62406

            ED Thoracotomy for Moribund Patients

            bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

            bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

            bull Aortic cross-clamping

            Optimizing Resuscitation Across the Continuum

            bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

            triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

            bullbull RegroupRegroup

            Damage Control Focus on Physiology

            bull Major paradigm shift in operative management of devastating injuries

            bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

            temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

            ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

            Damage Control Patient Selectionbull Instability

            bull Hypothermia (lt 34deg C)

            bull Coagulopathy

            bull Acidosis (pHlt 72BD -8)

            bull Major traumaAvoid ldquoground zero of damage control

            (physiological decompensation)

            Neurological All unconscious trauma patients have brain injury until proven otherwise

            bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

            bull Avoid hypotension in brain injured patients= poor outcome

            bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

            bull Urgent CT and expert neurosurgical care is a must

            Questions

            Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

            Summary and Conclusionsbull It is truly all about the

            patient

            bull Team effort and framework is needed by design

            bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

            bull Trauma centers save lives

            • Welcome to Trauma Tracks
            • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
            • OBJECTIVES
            • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
            • Current Outcomes for CY 2009
            • FRAMEWORK
            • ProfileCredentials of a Trauma Patient
            • FrameworkReadiness hyper-vigilance-- produces effective outcomes
            • FrameworkConsistent organization and clear cut communication produces effective outcomes
            • Slide Number 10
            • Slide Number 11
            • Slide Number 12
            • Slide Number 13
            • Situation Awareness
            • Most Potentially Preventable Trauma Deaths are related to
            • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
            • Optimizing Resuscitation Across the Continuum
            • Airway All trauma patients need oxygen until proven otherwise
            • Airway All unstable trauma patients need a definitive airway
            • Prehospital Intubation
            • Prehospital Intubation
            • The impact of prehospital ventilation on outcome after severe traumatic brain injury
            • Bridge Devices 2010
            • Breathing All trauma patients need oxygen until proven otherwise
            • CT Scan for thoracic trauma
            • Hemorrhage All trauma patients are bleeding until proven otherwise
            • Hemorrhage PEARL
            • Hemorrhage 5 Anatomic Areas of Origin
            • Hemorrhage Importance of Lactate amp BD
            • Persistent Acidosis Indicates
            • Base Deficit Categories
            • Uses of Base Deficit in Trauma Care
            • Resuscitation End Points
            • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
            • Goal Directed Therapy PEARL
            • Optimizing Prehospital Resuscitation
            • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
            • PrehospitalTopicals 2010Hemostatic Field Dressing
            • Tourniquets 2010
            • Indications for Tourniquets
            • Intraosseous Infusion Devices 2010
            • Blood Substitutes 2010
            • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
            • Pelvic Binders 2010
            • Optimizing ED Trauma Resuscitation (cont)
            • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
            • Slide Number 47
            • Slide Number 48
            • ED Thoracotomy for Moribund Patients
            • Optimizing Resuscitation Across the Continuum
            • Damage ControlFocus on Physiology
            • Damage Control Patient Selection
            • Neurological All unconscious trauma patients have brain injury until proven otherwise
            • Questions
            • Summary and Conclusions

              ProfileCredentials of a Trauma Patient

              bull Risk taking behaviorndash Drinking distracted

              speed out for funhellipbull Male vs Female

              ndash 75 malebull Average age (young)

              ndash Mean age 17bull Mechanism frequently

              Blunt trauma and acutely episodic

              ProfileCredentials of a Trauma Nurse

              bull Assertive behaviorndash Autonomous focused

              passionatehellipbull Female vs Male

              ndash 75 femalebull Average age (wise)

              ndash Mean age 46bull Mechanism frequently

              Continuous care for trauma patients is chronically perpetual

              Framework Readiness hyper-vigilance-- produces effective outcomesbull Pre-established

              trauma system based on experience from military

              bull 2020 vision from a distance-- expect the unexpected

              ldquoRed-tailed hawkrdquo

              Framework Consistent organization and clear cut communication produces effective outcomes

              bull Well established and maintained clear roles and goals

              bull Similar training- street through hospital

              bull Effective function of the team begins with the Team leader

              RRT

              CC TechSr Resident

              Jr Resident

              EM Resident

              Medical Student(HampPOrders)

              Nurse 2(Scribe)

              AttendingTrauma

              Sr ResidentPGY5PGY4PGY3

              FAST

              Introducer-Subclavian

              A-line-Femoral Artery

              EM AttendingED ResidentAirway- edentulate tongue RSI

              Breathing- end tidal CO2 ambu NGOGPupils TMrsquos

              Suturing scalp lac (no staples)

              Nurse 1Change field IVs to warm IVs Second IV Manual BP Vital signs including core temp Warming measures

              Attaches monitors BP pulse oximetry EKG electrodes End tidal CO2

              Monitors amp reports physiologic parametersAssists with procedures as appropriate

              Prepares patient for transportObtains equipment supplies medications

              X-RaysCXR Pelvis

              JR ResidentVacutainer

              Femoral ArteryABGs

              Lactic AcidHgbHct

              BMPPTPTT-Elderly CHI ampAnticoagulantsBA- all drivers

              ETOH suspicionRectal Exam

              Foley Catheter

              Nurse 2 (Scribe)Documentation on Trauma Flow Sheet Ensures overall coordination of room Completes lab slips applies patient

              bracelet places phone calls for orders diagnostics admission

              RadiologyTech

              RRTAirway adjuncts

              SuctioningEnd tidal CO2

              Ambu

              FAST

              Nurse 1

              CC TechAttaches monitors BP pulse

              oximetry EKG electrodes End tidal

              CO2Performs CPR

              Assists with procedure set-upsObtains equipment and

              supplies

              Charge NurseAssists with coordination

              of patient care

              i-STAT AttendingEM

              New TowerNew Tower

              NurseNursersquorsquos Stations Station

              Trauma Resuscitation RoomTrauma Resuscitation Room

              Trauma Resuscitation RoomTrauma Resuscitation Room

              Trauma Center Trauma Center EntranceEntrance

              Main EntranceMain Entrance

              Alberta-- first trauma alert

              Situation Awareness

              Detection(Perception)

              Patient

              Team

              Environment

              Tools

              Diagnosis

              Prediction

              PremiseCause of instability must be

              recognized and corrected quickly by using a systematic approach

              It is important to identify and prioritize systemic compromise

              Most Potentially Preventable Trauma Deaths are related to

              bull Airway obstruction

              bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

              Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

              1 All trauma patients need oxygen until proven otherwise

              2 All trauma patients are bleeding until proven otherwise

              3 All trauma patients have a cervical spine injury until proven otherwise

              4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

              Optimizing Resuscitation Across the Continuum

              bull Prehospital Phasendash Key patient

              information must be communicated

              bull Mechanismbull GCSbull Vital Signsbull Interventions

              ndash Be familiar with modalities and controversies

              Pay attention to episodic events of hypotension

              Airway All trauma patients need oxygen until proven otherwise

              bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

              bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

              bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

              Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

              unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

              of breathingmaximizes O2 delivery

              ndash Corrects acid base disturbances

              ndash Allow clinician to focus on other life-threatening issues

              Prehospital Intubation

              bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

              bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

              Prehospital Intubation

              bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

              bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

              bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

              The impact of prehospital ventilation on outcome after severe traumatic brain injury

              Cusheri et al JTrauma 2007 Jun62(6)1330-6

              BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

              determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

              impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

              with lower mortality after severe TBI

              Bridge Devices 2010

              LMAKing Airway

              Combitube

              Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

              25 of all trauma deathsbull Understand the significance of

              patternsndash 1st and 2nd rib fxs abdominal breathing

              bull Treat the pneumo before ETTbull Life-threatening thoracic

              injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

              1

              2

              CT Scan for thoracic trauma

              An occult pneumothorax seen on a CT scan that was not detected on a plain

              anteroposterior supine chest radiograph

              bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

              bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

              Hemorrhage All trauma patients are bleeding until proven otherwise

              bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

              bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

              bull Prevent shock by arresting the bleeding

              bull Mandates the earliest possible ldquogoal directed therapyrdquo

              Hemorrhage PEARLbull Recognize trouble

              ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

              increases morbidity and doubles mortality especially in head injured patients

              bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

              ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

              Hemorrhage 5 Anatomic Areas of Origin

              Kirkpatrick AW et al Can J Surg 200851(1)57-69

              Hemorrhage Importance of Lactate amp BD

              bull For Resuscitation to Occurndash Adequate perfusion and

              ndash Tissue oxygenation must be restored

              bull Measures Directed atndash Enhancing O2 transport and O2 uptake

              ndash Controlling the bleeding

              Persistent Acidosis Indicates

              bull Continued bleeding

              bull Inadequate resuscitation

              bull Myocardial dysfunction

              dArr

              serum pH (735 ndash 745)uArr

              base deficit (2 to -2)uArr

              serum lactate (04 ndash 18)

              Base Deficit Categories

              bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

              A base deficit of -6 is a marker of severeinjury amp significant mortality

              Uses of Base Deficit in Trauma Care

              bull Excellent correlation of base deficit to lactate and pH

              bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

              bull Assessing shock and efficacy of resuscitation

              bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

              Resuscitation End Points

              bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

              ndash Mentation

              ndash UO

              ndash Labs base deficit serum lactate serum pH

              Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

              urine output remain standard of carebull Uncompensated shock requires additional

              resuscitationbull However after normalizing the above up to 85 of

              severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

              bull Better markers of adequate resuscitation are needed

              Goal Directed Therapy PEARLbull Recognize trouble

              ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

              ndash Anticoagulantsndash Beta blockers

              bull Early invasive monitoringbull Follow resuscitation goals

              Optimizing Prehospital Resuscitation

              bull Low volume fluid administration in penetrating injuries

              bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

              sheetsbinderbull Tourniquetsbull Scoop and run transports

              based on ldquogolden hourrdquo

              ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

              bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

              bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

              Optimizing ResuscitationOptimizing Resuscitation

              Prehospital Topicals 2010 Hemostatic Field Dressing

              bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

              bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

              Tourniquets 2010

              40

              Indications for Tourniquetsbull Stop bleeding when life-

              threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

              bull Stop bleeding with traumatic amputation

              Intraosseous Infusion Devices 2010

              EZ-IO

              FAST1

              Blood Substitutes 2010

              bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

              bull Ready for prime time ndash not yet but soon - maybe

              bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

              ndash JAMA - April 28 2008

              Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

              bull Direct pressure to all external bleeding

              bull Rapid suturing of all scalp and facial wounds

              bull Rapid application of ThomasHare Traction splints for femur fx

              bull Binder for pelvic fxbull Rapid reduction and pressure

              dressings of mangled extremities

              Pelvic Binders 2010

              Optimizing ED Trauma Resuscitation (cont)

              bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

              Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

              bull Use FAST to rapidly detect intra-abdominal fluid

              bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

              floor during chest tube insertion

              Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

              bull Intervene early in resuscitation to STOP bleeding

              bull Conserve blood earlybull Aggressive rapid and efficient operative

              interventionsbull Use novel methods to STOP bleeding in the

              operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

              coagulopathy

              bull Controversialndash Whether to administer type and how much

              bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

              Optimizing ED Trauma Resuscitation- Fluid Resuscitation

              MTP Process Shands at UF

              Attending Fellow Chief ResidentActing Chief Resident initiates MTP

              amp notifies designated RN

              Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

              refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

              Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

              runner to BB with cross amp match

              MTP runner delivers blood products to designated RN

              Ismore MTPneeded

              EDOR ICU

              Designated RN assures bloodadministered per MD order

              Designated RN assures blood administered per MD order

              Designated RN sends MTP runner for more blood

              MTP site

              Ispt to be

              transported withblood

              Designated RN transportsblood with pt to location(ORICU)

              END

              END

              END

              YES NO

              YES

              NO

              ED = Nurse ScribeOR = Circ RN notifies

              Charge Nurse

              62406

              ED Thoracotomy for Moribund Patients

              bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

              bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

              bull Aortic cross-clamping

              Optimizing Resuscitation Across the Continuum

              bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

              triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

              bullbull RegroupRegroup

              Damage Control Focus on Physiology

              bull Major paradigm shift in operative management of devastating injuries

              bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

              temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

              ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

              Damage Control Patient Selectionbull Instability

              bull Hypothermia (lt 34deg C)

              bull Coagulopathy

              bull Acidosis (pHlt 72BD -8)

              bull Major traumaAvoid ldquoground zero of damage control

              (physiological decompensation)

              Neurological All unconscious trauma patients have brain injury until proven otherwise

              bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

              bull Avoid hypotension in brain injured patients= poor outcome

              bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

              bull Urgent CT and expert neurosurgical care is a must

              Questions

              Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

              Summary and Conclusionsbull It is truly all about the

              patient

              bull Team effort and framework is needed by design

              bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

              bull Trauma centers save lives

              • Welcome to Trauma Tracks
              • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
              • OBJECTIVES
              • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
              • Current Outcomes for CY 2009
              • FRAMEWORK
              • ProfileCredentials of a Trauma Patient
              • FrameworkReadiness hyper-vigilance-- produces effective outcomes
              • FrameworkConsistent organization and clear cut communication produces effective outcomes
              • Slide Number 10
              • Slide Number 11
              • Slide Number 12
              • Slide Number 13
              • Situation Awareness
              • Most Potentially Preventable Trauma Deaths are related to
              • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
              • Optimizing Resuscitation Across the Continuum
              • Airway All trauma patients need oxygen until proven otherwise
              • Airway All unstable trauma patients need a definitive airway
              • Prehospital Intubation
              • Prehospital Intubation
              • The impact of prehospital ventilation on outcome after severe traumatic brain injury
              • Bridge Devices 2010
              • Breathing All trauma patients need oxygen until proven otherwise
              • CT Scan for thoracic trauma
              • Hemorrhage All trauma patients are bleeding until proven otherwise
              • Hemorrhage PEARL
              • Hemorrhage 5 Anatomic Areas of Origin
              • Hemorrhage Importance of Lactate amp BD
              • Persistent Acidosis Indicates
              • Base Deficit Categories
              • Uses of Base Deficit in Trauma Care
              • Resuscitation End Points
              • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
              • Goal Directed Therapy PEARL
              • Optimizing Prehospital Resuscitation
              • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
              • PrehospitalTopicals 2010Hemostatic Field Dressing
              • Tourniquets 2010
              • Indications for Tourniquets
              • Intraosseous Infusion Devices 2010
              • Blood Substitutes 2010
              • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
              • Pelvic Binders 2010
              • Optimizing ED Trauma Resuscitation (cont)
              • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
              • Slide Number 47
              • Slide Number 48
              • ED Thoracotomy for Moribund Patients
              • Optimizing Resuscitation Across the Continuum
              • Damage ControlFocus on Physiology
              • Damage Control Patient Selection
              • Neurological All unconscious trauma patients have brain injury until proven otherwise
              • Questions
              • Summary and Conclusions

                Framework Readiness hyper-vigilance-- produces effective outcomesbull Pre-established

                trauma system based on experience from military

                bull 2020 vision from a distance-- expect the unexpected

                ldquoRed-tailed hawkrdquo

                Framework Consistent organization and clear cut communication produces effective outcomes

                bull Well established and maintained clear roles and goals

                bull Similar training- street through hospital

                bull Effective function of the team begins with the Team leader

                RRT

                CC TechSr Resident

                Jr Resident

                EM Resident

                Medical Student(HampPOrders)

                Nurse 2(Scribe)

                AttendingTrauma

                Sr ResidentPGY5PGY4PGY3

                FAST

                Introducer-Subclavian

                A-line-Femoral Artery

                EM AttendingED ResidentAirway- edentulate tongue RSI

                Breathing- end tidal CO2 ambu NGOGPupils TMrsquos

                Suturing scalp lac (no staples)

                Nurse 1Change field IVs to warm IVs Second IV Manual BP Vital signs including core temp Warming measures

                Attaches monitors BP pulse oximetry EKG electrodes End tidal CO2

                Monitors amp reports physiologic parametersAssists with procedures as appropriate

                Prepares patient for transportObtains equipment supplies medications

                X-RaysCXR Pelvis

                JR ResidentVacutainer

                Femoral ArteryABGs

                Lactic AcidHgbHct

                BMPPTPTT-Elderly CHI ampAnticoagulantsBA- all drivers

                ETOH suspicionRectal Exam

                Foley Catheter

                Nurse 2 (Scribe)Documentation on Trauma Flow Sheet Ensures overall coordination of room Completes lab slips applies patient

                bracelet places phone calls for orders diagnostics admission

                RadiologyTech

                RRTAirway adjuncts

                SuctioningEnd tidal CO2

                Ambu

                FAST

                Nurse 1

                CC TechAttaches monitors BP pulse

                oximetry EKG electrodes End tidal

                CO2Performs CPR

                Assists with procedure set-upsObtains equipment and

                supplies

                Charge NurseAssists with coordination

                of patient care

                i-STAT AttendingEM

                New TowerNew Tower

                NurseNursersquorsquos Stations Station

                Trauma Resuscitation RoomTrauma Resuscitation Room

                Trauma Resuscitation RoomTrauma Resuscitation Room

                Trauma Center Trauma Center EntranceEntrance

                Main EntranceMain Entrance

                Alberta-- first trauma alert

                Situation Awareness

                Detection(Perception)

                Patient

                Team

                Environment

                Tools

                Diagnosis

                Prediction

                PremiseCause of instability must be

                recognized and corrected quickly by using a systematic approach

                It is important to identify and prioritize systemic compromise

                Most Potentially Preventable Trauma Deaths are related to

                bull Airway obstruction

                bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

                Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

                1 All trauma patients need oxygen until proven otherwise

                2 All trauma patients are bleeding until proven otherwise

                3 All trauma patients have a cervical spine injury until proven otherwise

                4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

                Optimizing Resuscitation Across the Continuum

                bull Prehospital Phasendash Key patient

                information must be communicated

                bull Mechanismbull GCSbull Vital Signsbull Interventions

                ndash Be familiar with modalities and controversies

                Pay attention to episodic events of hypotension

                Airway All trauma patients need oxygen until proven otherwise

                bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

                bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

                bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

                Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                of breathingmaximizes O2 delivery

                ndash Corrects acid base disturbances

                ndash Allow clinician to focus on other life-threatening issues

                Prehospital Intubation

                bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                Prehospital Intubation

                bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                The impact of prehospital ventilation on outcome after severe traumatic brain injury

                Cusheri et al JTrauma 2007 Jun62(6)1330-6

                BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                with lower mortality after severe TBI

                Bridge Devices 2010

                LMAKing Airway

                Combitube

                Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                25 of all trauma deathsbull Understand the significance of

                patternsndash 1st and 2nd rib fxs abdominal breathing

                bull Treat the pneumo before ETTbull Life-threatening thoracic

                injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                1

                2

                CT Scan for thoracic trauma

                An occult pneumothorax seen on a CT scan that was not detected on a plain

                anteroposterior supine chest radiograph

                bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                Hemorrhage All trauma patients are bleeding until proven otherwise

                bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                bull Prevent shock by arresting the bleeding

                bull Mandates the earliest possible ldquogoal directed therapyrdquo

                Hemorrhage PEARLbull Recognize trouble

                ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                increases morbidity and doubles mortality especially in head injured patients

                bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                Hemorrhage 5 Anatomic Areas of Origin

                Kirkpatrick AW et al Can J Surg 200851(1)57-69

                Hemorrhage Importance of Lactate amp BD

                bull For Resuscitation to Occurndash Adequate perfusion and

                ndash Tissue oxygenation must be restored

                bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                ndash Controlling the bleeding

                Persistent Acidosis Indicates

                bull Continued bleeding

                bull Inadequate resuscitation

                bull Myocardial dysfunction

                dArr

                serum pH (735 ndash 745)uArr

                base deficit (2 to -2)uArr

                serum lactate (04 ndash 18)

                Base Deficit Categories

                bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                A base deficit of -6 is a marker of severeinjury amp significant mortality

                Uses of Base Deficit in Trauma Care

                bull Excellent correlation of base deficit to lactate and pH

                bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                bull Assessing shock and efficacy of resuscitation

                bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                Resuscitation End Points

                bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                ndash Mentation

                ndash UO

                ndash Labs base deficit serum lactate serum pH

                Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                urine output remain standard of carebull Uncompensated shock requires additional

                resuscitationbull However after normalizing the above up to 85 of

                severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                bull Better markers of adequate resuscitation are needed

                Goal Directed Therapy PEARLbull Recognize trouble

                ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                ndash Anticoagulantsndash Beta blockers

                bull Early invasive monitoringbull Follow resuscitation goals

                Optimizing Prehospital Resuscitation

                bull Low volume fluid administration in penetrating injuries

                bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                sheetsbinderbull Tourniquetsbull Scoop and run transports

                based on ldquogolden hourrdquo

                ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                Optimizing ResuscitationOptimizing Resuscitation

                Prehospital Topicals 2010 Hemostatic Field Dressing

                bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                Tourniquets 2010

                40

                Indications for Tourniquetsbull Stop bleeding when life-

                threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                bull Stop bleeding with traumatic amputation

                Intraosseous Infusion Devices 2010

                EZ-IO

                FAST1

                Blood Substitutes 2010

                bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                bull Ready for prime time ndash not yet but soon - maybe

                bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                ndash JAMA - April 28 2008

                Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                bull Direct pressure to all external bleeding

                bull Rapid suturing of all scalp and facial wounds

                bull Rapid application of ThomasHare Traction splints for femur fx

                bull Binder for pelvic fxbull Rapid reduction and pressure

                dressings of mangled extremities

                Pelvic Binders 2010

                Optimizing ED Trauma Resuscitation (cont)

                bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                bull Use FAST to rapidly detect intra-abdominal fluid

                bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                floor during chest tube insertion

                Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                bull Intervene early in resuscitation to STOP bleeding

                bull Conserve blood earlybull Aggressive rapid and efficient operative

                interventionsbull Use novel methods to STOP bleeding in the

                operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                coagulopathy

                bull Controversialndash Whether to administer type and how much

                bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                MTP Process Shands at UF

                Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                amp notifies designated RN

                Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                runner to BB with cross amp match

                MTP runner delivers blood products to designated RN

                Ismore MTPneeded

                EDOR ICU

                Designated RN assures bloodadministered per MD order

                Designated RN assures blood administered per MD order

                Designated RN sends MTP runner for more blood

                MTP site

                Ispt to be

                transported withblood

                Designated RN transportsblood with pt to location(ORICU)

                END

                END

                END

                YES NO

                YES

                NO

                ED = Nurse ScribeOR = Circ RN notifies

                Charge Nurse

                62406

                ED Thoracotomy for Moribund Patients

                bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                bull Aortic cross-clamping

                Optimizing Resuscitation Across the Continuum

                bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                bullbull RegroupRegroup

                Damage Control Focus on Physiology

                bull Major paradigm shift in operative management of devastating injuries

                bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                Damage Control Patient Selectionbull Instability

                bull Hypothermia (lt 34deg C)

                bull Coagulopathy

                bull Acidosis (pHlt 72BD -8)

                bull Major traumaAvoid ldquoground zero of damage control

                (physiological decompensation)

                Neurological All unconscious trauma patients have brain injury until proven otherwise

                bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                bull Avoid hypotension in brain injured patients= poor outcome

                bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                bull Urgent CT and expert neurosurgical care is a must

                Questions

                Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                Summary and Conclusionsbull It is truly all about the

                patient

                bull Team effort and framework is needed by design

                bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                bull Trauma centers save lives

                • Welcome to Trauma Tracks
                • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                • OBJECTIVES
                • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                • Current Outcomes for CY 2009
                • FRAMEWORK
                • ProfileCredentials of a Trauma Patient
                • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                • FrameworkConsistent organization and clear cut communication produces effective outcomes
                • Slide Number 10
                • Slide Number 11
                • Slide Number 12
                • Slide Number 13
                • Situation Awareness
                • Most Potentially Preventable Trauma Deaths are related to
                • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                • Optimizing Resuscitation Across the Continuum
                • Airway All trauma patients need oxygen until proven otherwise
                • Airway All unstable trauma patients need a definitive airway
                • Prehospital Intubation
                • Prehospital Intubation
                • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                • Bridge Devices 2010
                • Breathing All trauma patients need oxygen until proven otherwise
                • CT Scan for thoracic trauma
                • Hemorrhage All trauma patients are bleeding until proven otherwise
                • Hemorrhage PEARL
                • Hemorrhage 5 Anatomic Areas of Origin
                • Hemorrhage Importance of Lactate amp BD
                • Persistent Acidosis Indicates
                • Base Deficit Categories
                • Uses of Base Deficit in Trauma Care
                • Resuscitation End Points
                • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                • Goal Directed Therapy PEARL
                • Optimizing Prehospital Resuscitation
                • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                • PrehospitalTopicals 2010Hemostatic Field Dressing
                • Tourniquets 2010
                • Indications for Tourniquets
                • Intraosseous Infusion Devices 2010
                • Blood Substitutes 2010
                • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                • Pelvic Binders 2010
                • Optimizing ED Trauma Resuscitation (cont)
                • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                • Slide Number 47
                • Slide Number 48
                • ED Thoracotomy for Moribund Patients
                • Optimizing Resuscitation Across the Continuum
                • Damage ControlFocus on Physiology
                • Damage Control Patient Selection
                • Neurological All unconscious trauma patients have brain injury until proven otherwise
                • Questions
                • Summary and Conclusions

                  Framework Consistent organization and clear cut communication produces effective outcomes

                  bull Well established and maintained clear roles and goals

                  bull Similar training- street through hospital

                  bull Effective function of the team begins with the Team leader

                  RRT

                  CC TechSr Resident

                  Jr Resident

                  EM Resident

                  Medical Student(HampPOrders)

                  Nurse 2(Scribe)

                  AttendingTrauma

                  Sr ResidentPGY5PGY4PGY3

                  FAST

                  Introducer-Subclavian

                  A-line-Femoral Artery

                  EM AttendingED ResidentAirway- edentulate tongue RSI

                  Breathing- end tidal CO2 ambu NGOGPupils TMrsquos

                  Suturing scalp lac (no staples)

                  Nurse 1Change field IVs to warm IVs Second IV Manual BP Vital signs including core temp Warming measures

                  Attaches monitors BP pulse oximetry EKG electrodes End tidal CO2

                  Monitors amp reports physiologic parametersAssists with procedures as appropriate

                  Prepares patient for transportObtains equipment supplies medications

                  X-RaysCXR Pelvis

                  JR ResidentVacutainer

                  Femoral ArteryABGs

                  Lactic AcidHgbHct

                  BMPPTPTT-Elderly CHI ampAnticoagulantsBA- all drivers

                  ETOH suspicionRectal Exam

                  Foley Catheter

                  Nurse 2 (Scribe)Documentation on Trauma Flow Sheet Ensures overall coordination of room Completes lab slips applies patient

                  bracelet places phone calls for orders diagnostics admission

                  RadiologyTech

                  RRTAirway adjuncts

                  SuctioningEnd tidal CO2

                  Ambu

                  FAST

                  Nurse 1

                  CC TechAttaches monitors BP pulse

                  oximetry EKG electrodes End tidal

                  CO2Performs CPR

                  Assists with procedure set-upsObtains equipment and

                  supplies

                  Charge NurseAssists with coordination

                  of patient care

                  i-STAT AttendingEM

                  New TowerNew Tower

                  NurseNursersquorsquos Stations Station

                  Trauma Resuscitation RoomTrauma Resuscitation Room

                  Trauma Resuscitation RoomTrauma Resuscitation Room

                  Trauma Center Trauma Center EntranceEntrance

                  Main EntranceMain Entrance

                  Alberta-- first trauma alert

                  Situation Awareness

                  Detection(Perception)

                  Patient

                  Team

                  Environment

                  Tools

                  Diagnosis

                  Prediction

                  PremiseCause of instability must be

                  recognized and corrected quickly by using a systematic approach

                  It is important to identify and prioritize systemic compromise

                  Most Potentially Preventable Trauma Deaths are related to

                  bull Airway obstruction

                  bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

                  Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

                  1 All trauma patients need oxygen until proven otherwise

                  2 All trauma patients are bleeding until proven otherwise

                  3 All trauma patients have a cervical spine injury until proven otherwise

                  4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

                  Optimizing Resuscitation Across the Continuum

                  bull Prehospital Phasendash Key patient

                  information must be communicated

                  bull Mechanismbull GCSbull Vital Signsbull Interventions

                  ndash Be familiar with modalities and controversies

                  Pay attention to episodic events of hypotension

                  Airway All trauma patients need oxygen until proven otherwise

                  bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

                  bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

                  bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

                  Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                  unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                  of breathingmaximizes O2 delivery

                  ndash Corrects acid base disturbances

                  ndash Allow clinician to focus on other life-threatening issues

                  Prehospital Intubation

                  bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                  bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                  Prehospital Intubation

                  bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                  bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                  bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                  The impact of prehospital ventilation on outcome after severe traumatic brain injury

                  Cusheri et al JTrauma 2007 Jun62(6)1330-6

                  BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                  determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                  impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                  with lower mortality after severe TBI

                  Bridge Devices 2010

                  LMAKing Airway

                  Combitube

                  Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                  25 of all trauma deathsbull Understand the significance of

                  patternsndash 1st and 2nd rib fxs abdominal breathing

                  bull Treat the pneumo before ETTbull Life-threatening thoracic

                  injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                  1

                  2

                  CT Scan for thoracic trauma

                  An occult pneumothorax seen on a CT scan that was not detected on a plain

                  anteroposterior supine chest radiograph

                  bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                  bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                  Hemorrhage All trauma patients are bleeding until proven otherwise

                  bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                  bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                  bull Prevent shock by arresting the bleeding

                  bull Mandates the earliest possible ldquogoal directed therapyrdquo

                  Hemorrhage PEARLbull Recognize trouble

                  ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                  increases morbidity and doubles mortality especially in head injured patients

                  bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                  ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                  Hemorrhage 5 Anatomic Areas of Origin

                  Kirkpatrick AW et al Can J Surg 200851(1)57-69

                  Hemorrhage Importance of Lactate amp BD

                  bull For Resuscitation to Occurndash Adequate perfusion and

                  ndash Tissue oxygenation must be restored

                  bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                  ndash Controlling the bleeding

                  Persistent Acidosis Indicates

                  bull Continued bleeding

                  bull Inadequate resuscitation

                  bull Myocardial dysfunction

                  dArr

                  serum pH (735 ndash 745)uArr

                  base deficit (2 to -2)uArr

                  serum lactate (04 ndash 18)

                  Base Deficit Categories

                  bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                  A base deficit of -6 is a marker of severeinjury amp significant mortality

                  Uses of Base Deficit in Trauma Care

                  bull Excellent correlation of base deficit to lactate and pH

                  bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                  bull Assessing shock and efficacy of resuscitation

                  bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                  Resuscitation End Points

                  bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                  ndash Mentation

                  ndash UO

                  ndash Labs base deficit serum lactate serum pH

                  Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                  urine output remain standard of carebull Uncompensated shock requires additional

                  resuscitationbull However after normalizing the above up to 85 of

                  severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                  bull Better markers of adequate resuscitation are needed

                  Goal Directed Therapy PEARLbull Recognize trouble

                  ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                  ndash Anticoagulantsndash Beta blockers

                  bull Early invasive monitoringbull Follow resuscitation goals

                  Optimizing Prehospital Resuscitation

                  bull Low volume fluid administration in penetrating injuries

                  bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                  sheetsbinderbull Tourniquetsbull Scoop and run transports

                  based on ldquogolden hourrdquo

                  ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                  bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                  bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                  Optimizing ResuscitationOptimizing Resuscitation

                  Prehospital Topicals 2010 Hemostatic Field Dressing

                  bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                  bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                  Tourniquets 2010

                  40

                  Indications for Tourniquetsbull Stop bleeding when life-

                  threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                  bull Stop bleeding with traumatic amputation

                  Intraosseous Infusion Devices 2010

                  EZ-IO

                  FAST1

                  Blood Substitutes 2010

                  bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                  bull Ready for prime time ndash not yet but soon - maybe

                  bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                  ndash JAMA - April 28 2008

                  Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                  bull Direct pressure to all external bleeding

                  bull Rapid suturing of all scalp and facial wounds

                  bull Rapid application of ThomasHare Traction splints for femur fx

                  bull Binder for pelvic fxbull Rapid reduction and pressure

                  dressings of mangled extremities

                  Pelvic Binders 2010

                  Optimizing ED Trauma Resuscitation (cont)

                  bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                  Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                  bull Use FAST to rapidly detect intra-abdominal fluid

                  bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                  floor during chest tube insertion

                  Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                  bull Intervene early in resuscitation to STOP bleeding

                  bull Conserve blood earlybull Aggressive rapid and efficient operative

                  interventionsbull Use novel methods to STOP bleeding in the

                  operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                  coagulopathy

                  bull Controversialndash Whether to administer type and how much

                  bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                  Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                  MTP Process Shands at UF

                  Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                  amp notifies designated RN

                  Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                  refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                  Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                  runner to BB with cross amp match

                  MTP runner delivers blood products to designated RN

                  Ismore MTPneeded

                  EDOR ICU

                  Designated RN assures bloodadministered per MD order

                  Designated RN assures blood administered per MD order

                  Designated RN sends MTP runner for more blood

                  MTP site

                  Ispt to be

                  transported withblood

                  Designated RN transportsblood with pt to location(ORICU)

                  END

                  END

                  END

                  YES NO

                  YES

                  NO

                  ED = Nurse ScribeOR = Circ RN notifies

                  Charge Nurse

                  62406

                  ED Thoracotomy for Moribund Patients

                  bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                  bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                  bull Aortic cross-clamping

                  Optimizing Resuscitation Across the Continuum

                  bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                  triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                  bullbull RegroupRegroup

                  Damage Control Focus on Physiology

                  bull Major paradigm shift in operative management of devastating injuries

                  bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                  temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                  ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                  Damage Control Patient Selectionbull Instability

                  bull Hypothermia (lt 34deg C)

                  bull Coagulopathy

                  bull Acidosis (pHlt 72BD -8)

                  bull Major traumaAvoid ldquoground zero of damage control

                  (physiological decompensation)

                  Neurological All unconscious trauma patients have brain injury until proven otherwise

                  bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                  bull Avoid hypotension in brain injured patients= poor outcome

                  bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                  bull Urgent CT and expert neurosurgical care is a must

                  Questions

                  Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                  Summary and Conclusionsbull It is truly all about the

                  patient

                  bull Team effort and framework is needed by design

                  bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                  bull Trauma centers save lives

                  • Welcome to Trauma Tracks
                  • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                  • OBJECTIVES
                  • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                  • Current Outcomes for CY 2009
                  • FRAMEWORK
                  • ProfileCredentials of a Trauma Patient
                  • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                  • FrameworkConsistent organization and clear cut communication produces effective outcomes
                  • Slide Number 10
                  • Slide Number 11
                  • Slide Number 12
                  • Slide Number 13
                  • Situation Awareness
                  • Most Potentially Preventable Trauma Deaths are related to
                  • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                  • Optimizing Resuscitation Across the Continuum
                  • Airway All trauma patients need oxygen until proven otherwise
                  • Airway All unstable trauma patients need a definitive airway
                  • Prehospital Intubation
                  • Prehospital Intubation
                  • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                  • Bridge Devices 2010
                  • Breathing All trauma patients need oxygen until proven otherwise
                  • CT Scan for thoracic trauma
                  • Hemorrhage All trauma patients are bleeding until proven otherwise
                  • Hemorrhage PEARL
                  • Hemorrhage 5 Anatomic Areas of Origin
                  • Hemorrhage Importance of Lactate amp BD
                  • Persistent Acidosis Indicates
                  • Base Deficit Categories
                  • Uses of Base Deficit in Trauma Care
                  • Resuscitation End Points
                  • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                  • Goal Directed Therapy PEARL
                  • Optimizing Prehospital Resuscitation
                  • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                  • PrehospitalTopicals 2010Hemostatic Field Dressing
                  • Tourniquets 2010
                  • Indications for Tourniquets
                  • Intraosseous Infusion Devices 2010
                  • Blood Substitutes 2010
                  • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                  • Pelvic Binders 2010
                  • Optimizing ED Trauma Resuscitation (cont)
                  • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                  • Slide Number 47
                  • Slide Number 48
                  • ED Thoracotomy for Moribund Patients
                  • Optimizing Resuscitation Across the Continuum
                  • Damage ControlFocus on Physiology
                  • Damage Control Patient Selection
                  • Neurological All unconscious trauma patients have brain injury until proven otherwise
                  • Questions
                  • Summary and Conclusions

                    RRT

                    CC TechSr Resident

                    Jr Resident

                    EM Resident

                    Medical Student(HampPOrders)

                    Nurse 2(Scribe)

                    AttendingTrauma

                    Sr ResidentPGY5PGY4PGY3

                    FAST

                    Introducer-Subclavian

                    A-line-Femoral Artery

                    EM AttendingED ResidentAirway- edentulate tongue RSI

                    Breathing- end tidal CO2 ambu NGOGPupils TMrsquos

                    Suturing scalp lac (no staples)

                    Nurse 1Change field IVs to warm IVs Second IV Manual BP Vital signs including core temp Warming measures

                    Attaches monitors BP pulse oximetry EKG electrodes End tidal CO2

                    Monitors amp reports physiologic parametersAssists with procedures as appropriate

                    Prepares patient for transportObtains equipment supplies medications

                    X-RaysCXR Pelvis

                    JR ResidentVacutainer

                    Femoral ArteryABGs

                    Lactic AcidHgbHct

                    BMPPTPTT-Elderly CHI ampAnticoagulantsBA- all drivers

                    ETOH suspicionRectal Exam

                    Foley Catheter

                    Nurse 2 (Scribe)Documentation on Trauma Flow Sheet Ensures overall coordination of room Completes lab slips applies patient

                    bracelet places phone calls for orders diagnostics admission

                    RadiologyTech

                    RRTAirway adjuncts

                    SuctioningEnd tidal CO2

                    Ambu

                    FAST

                    Nurse 1

                    CC TechAttaches monitors BP pulse

                    oximetry EKG electrodes End tidal

                    CO2Performs CPR

                    Assists with procedure set-upsObtains equipment and

                    supplies

                    Charge NurseAssists with coordination

                    of patient care

                    i-STAT AttendingEM

                    New TowerNew Tower

                    NurseNursersquorsquos Stations Station

                    Trauma Resuscitation RoomTrauma Resuscitation Room

                    Trauma Resuscitation RoomTrauma Resuscitation Room

                    Trauma Center Trauma Center EntranceEntrance

                    Main EntranceMain Entrance

                    Alberta-- first trauma alert

                    Situation Awareness

                    Detection(Perception)

                    Patient

                    Team

                    Environment

                    Tools

                    Diagnosis

                    Prediction

                    PremiseCause of instability must be

                    recognized and corrected quickly by using a systematic approach

                    It is important to identify and prioritize systemic compromise

                    Most Potentially Preventable Trauma Deaths are related to

                    bull Airway obstruction

                    bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

                    Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

                    1 All trauma patients need oxygen until proven otherwise

                    2 All trauma patients are bleeding until proven otherwise

                    3 All trauma patients have a cervical spine injury until proven otherwise

                    4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

                    Optimizing Resuscitation Across the Continuum

                    bull Prehospital Phasendash Key patient

                    information must be communicated

                    bull Mechanismbull GCSbull Vital Signsbull Interventions

                    ndash Be familiar with modalities and controversies

                    Pay attention to episodic events of hypotension

                    Airway All trauma patients need oxygen until proven otherwise

                    bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

                    bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

                    bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

                    Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                    unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                    of breathingmaximizes O2 delivery

                    ndash Corrects acid base disturbances

                    ndash Allow clinician to focus on other life-threatening issues

                    Prehospital Intubation

                    bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                    bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                    Prehospital Intubation

                    bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                    bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                    bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                    The impact of prehospital ventilation on outcome after severe traumatic brain injury

                    Cusheri et al JTrauma 2007 Jun62(6)1330-6

                    BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                    determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                    impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                    with lower mortality after severe TBI

                    Bridge Devices 2010

                    LMAKing Airway

                    Combitube

                    Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                    25 of all trauma deathsbull Understand the significance of

                    patternsndash 1st and 2nd rib fxs abdominal breathing

                    bull Treat the pneumo before ETTbull Life-threatening thoracic

                    injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                    1

                    2

                    CT Scan for thoracic trauma

                    An occult pneumothorax seen on a CT scan that was not detected on a plain

                    anteroposterior supine chest radiograph

                    bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                    bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                    Hemorrhage All trauma patients are bleeding until proven otherwise

                    bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                    bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                    bull Prevent shock by arresting the bleeding

                    bull Mandates the earliest possible ldquogoal directed therapyrdquo

                    Hemorrhage PEARLbull Recognize trouble

                    ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                    increases morbidity and doubles mortality especially in head injured patients

                    bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                    ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                    Hemorrhage 5 Anatomic Areas of Origin

                    Kirkpatrick AW et al Can J Surg 200851(1)57-69

                    Hemorrhage Importance of Lactate amp BD

                    bull For Resuscitation to Occurndash Adequate perfusion and

                    ndash Tissue oxygenation must be restored

                    bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                    ndash Controlling the bleeding

                    Persistent Acidosis Indicates

                    bull Continued bleeding

                    bull Inadequate resuscitation

                    bull Myocardial dysfunction

                    dArr

                    serum pH (735 ndash 745)uArr

                    base deficit (2 to -2)uArr

                    serum lactate (04 ndash 18)

                    Base Deficit Categories

                    bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                    A base deficit of -6 is a marker of severeinjury amp significant mortality

                    Uses of Base Deficit in Trauma Care

                    bull Excellent correlation of base deficit to lactate and pH

                    bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                    bull Assessing shock and efficacy of resuscitation

                    bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                    Resuscitation End Points

                    bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                    ndash Mentation

                    ndash UO

                    ndash Labs base deficit serum lactate serum pH

                    Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                    urine output remain standard of carebull Uncompensated shock requires additional

                    resuscitationbull However after normalizing the above up to 85 of

                    severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                    bull Better markers of adequate resuscitation are needed

                    Goal Directed Therapy PEARLbull Recognize trouble

                    ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                    ndash Anticoagulantsndash Beta blockers

                    bull Early invasive monitoringbull Follow resuscitation goals

                    Optimizing Prehospital Resuscitation

                    bull Low volume fluid administration in penetrating injuries

                    bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                    sheetsbinderbull Tourniquetsbull Scoop and run transports

                    based on ldquogolden hourrdquo

                    ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                    bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                    bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                    Optimizing ResuscitationOptimizing Resuscitation

                    Prehospital Topicals 2010 Hemostatic Field Dressing

                    bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                    bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                    Tourniquets 2010

                    40

                    Indications for Tourniquetsbull Stop bleeding when life-

                    threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                    bull Stop bleeding with traumatic amputation

                    Intraosseous Infusion Devices 2010

                    EZ-IO

                    FAST1

                    Blood Substitutes 2010

                    bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                    bull Ready for prime time ndash not yet but soon - maybe

                    bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                    ndash JAMA - April 28 2008

                    Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                    bull Direct pressure to all external bleeding

                    bull Rapid suturing of all scalp and facial wounds

                    bull Rapid application of ThomasHare Traction splints for femur fx

                    bull Binder for pelvic fxbull Rapid reduction and pressure

                    dressings of mangled extremities

                    Pelvic Binders 2010

                    Optimizing ED Trauma Resuscitation (cont)

                    bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                    Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                    bull Use FAST to rapidly detect intra-abdominal fluid

                    bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                    floor during chest tube insertion

                    Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                    bull Intervene early in resuscitation to STOP bleeding

                    bull Conserve blood earlybull Aggressive rapid and efficient operative

                    interventionsbull Use novel methods to STOP bleeding in the

                    operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                    coagulopathy

                    bull Controversialndash Whether to administer type and how much

                    bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                    Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                    MTP Process Shands at UF

                    Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                    amp notifies designated RN

                    Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                    refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                    Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                    runner to BB with cross amp match

                    MTP runner delivers blood products to designated RN

                    Ismore MTPneeded

                    EDOR ICU

                    Designated RN assures bloodadministered per MD order

                    Designated RN assures blood administered per MD order

                    Designated RN sends MTP runner for more blood

                    MTP site

                    Ispt to be

                    transported withblood

                    Designated RN transportsblood with pt to location(ORICU)

                    END

                    END

                    END

                    YES NO

                    YES

                    NO

                    ED = Nurse ScribeOR = Circ RN notifies

                    Charge Nurse

                    62406

                    ED Thoracotomy for Moribund Patients

                    bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                    bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                    bull Aortic cross-clamping

                    Optimizing Resuscitation Across the Continuum

                    bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                    triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                    bullbull RegroupRegroup

                    Damage Control Focus on Physiology

                    bull Major paradigm shift in operative management of devastating injuries

                    bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                    temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                    ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                    Damage Control Patient Selectionbull Instability

                    bull Hypothermia (lt 34deg C)

                    bull Coagulopathy

                    bull Acidosis (pHlt 72BD -8)

                    bull Major traumaAvoid ldquoground zero of damage control

                    (physiological decompensation)

                    Neurological All unconscious trauma patients have brain injury until proven otherwise

                    bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                    bull Avoid hypotension in brain injured patients= poor outcome

                    bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                    bull Urgent CT and expert neurosurgical care is a must

                    Questions

                    Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                    Summary and Conclusionsbull It is truly all about the

                    patient

                    bull Team effort and framework is needed by design

                    bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                    bull Trauma centers save lives

                    • Welcome to Trauma Tracks
                    • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                    • OBJECTIVES
                    • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                    • Current Outcomes for CY 2009
                    • FRAMEWORK
                    • ProfileCredentials of a Trauma Patient
                    • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                    • FrameworkConsistent organization and clear cut communication produces effective outcomes
                    • Slide Number 10
                    • Slide Number 11
                    • Slide Number 12
                    • Slide Number 13
                    • Situation Awareness
                    • Most Potentially Preventable Trauma Deaths are related to
                    • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                    • Optimizing Resuscitation Across the Continuum
                    • Airway All trauma patients need oxygen until proven otherwise
                    • Airway All unstable trauma patients need a definitive airway
                    • Prehospital Intubation
                    • Prehospital Intubation
                    • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                    • Bridge Devices 2010
                    • Breathing All trauma patients need oxygen until proven otherwise
                    • CT Scan for thoracic trauma
                    • Hemorrhage All trauma patients are bleeding until proven otherwise
                    • Hemorrhage PEARL
                    • Hemorrhage 5 Anatomic Areas of Origin
                    • Hemorrhage Importance of Lactate amp BD
                    • Persistent Acidosis Indicates
                    • Base Deficit Categories
                    • Uses of Base Deficit in Trauma Care
                    • Resuscitation End Points
                    • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                    • Goal Directed Therapy PEARL
                    • Optimizing Prehospital Resuscitation
                    • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                    • PrehospitalTopicals 2010Hemostatic Field Dressing
                    • Tourniquets 2010
                    • Indications for Tourniquets
                    • Intraosseous Infusion Devices 2010
                    • Blood Substitutes 2010
                    • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                    • Pelvic Binders 2010
                    • Optimizing ED Trauma Resuscitation (cont)
                    • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                    • Slide Number 47
                    • Slide Number 48
                    • ED Thoracotomy for Moribund Patients
                    • Optimizing Resuscitation Across the Continuum
                    • Damage ControlFocus on Physiology
                    • Damage Control Patient Selection
                    • Neurological All unconscious trauma patients have brain injury until proven otherwise
                    • Questions
                    • Summary and Conclusions

                      New TowerNew Tower

                      NurseNursersquorsquos Stations Station

                      Trauma Resuscitation RoomTrauma Resuscitation Room

                      Trauma Resuscitation RoomTrauma Resuscitation Room

                      Trauma Center Trauma Center EntranceEntrance

                      Main EntranceMain Entrance

                      Alberta-- first trauma alert

                      Situation Awareness

                      Detection(Perception)

                      Patient

                      Team

                      Environment

                      Tools

                      Diagnosis

                      Prediction

                      PremiseCause of instability must be

                      recognized and corrected quickly by using a systematic approach

                      It is important to identify and prioritize systemic compromise

                      Most Potentially Preventable Trauma Deaths are related to

                      bull Airway obstruction

                      bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

                      Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

                      1 All trauma patients need oxygen until proven otherwise

                      2 All trauma patients are bleeding until proven otherwise

                      3 All trauma patients have a cervical spine injury until proven otherwise

                      4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

                      Optimizing Resuscitation Across the Continuum

                      bull Prehospital Phasendash Key patient

                      information must be communicated

                      bull Mechanismbull GCSbull Vital Signsbull Interventions

                      ndash Be familiar with modalities and controversies

                      Pay attention to episodic events of hypotension

                      Airway All trauma patients need oxygen until proven otherwise

                      bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

                      bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

                      bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

                      Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                      unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                      of breathingmaximizes O2 delivery

                      ndash Corrects acid base disturbances

                      ndash Allow clinician to focus on other life-threatening issues

                      Prehospital Intubation

                      bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                      bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                      Prehospital Intubation

                      bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                      bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                      bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                      The impact of prehospital ventilation on outcome after severe traumatic brain injury

                      Cusheri et al JTrauma 2007 Jun62(6)1330-6

                      BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                      determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                      impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                      with lower mortality after severe TBI

                      Bridge Devices 2010

                      LMAKing Airway

                      Combitube

                      Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                      25 of all trauma deathsbull Understand the significance of

                      patternsndash 1st and 2nd rib fxs abdominal breathing

                      bull Treat the pneumo before ETTbull Life-threatening thoracic

                      injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                      1

                      2

                      CT Scan for thoracic trauma

                      An occult pneumothorax seen on a CT scan that was not detected on a plain

                      anteroposterior supine chest radiograph

                      bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                      bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                      Hemorrhage All trauma patients are bleeding until proven otherwise

                      bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                      bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                      bull Prevent shock by arresting the bleeding

                      bull Mandates the earliest possible ldquogoal directed therapyrdquo

                      Hemorrhage PEARLbull Recognize trouble

                      ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                      increases morbidity and doubles mortality especially in head injured patients

                      bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                      ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                      Hemorrhage 5 Anatomic Areas of Origin

                      Kirkpatrick AW et al Can J Surg 200851(1)57-69

                      Hemorrhage Importance of Lactate amp BD

                      bull For Resuscitation to Occurndash Adequate perfusion and

                      ndash Tissue oxygenation must be restored

                      bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                      ndash Controlling the bleeding

                      Persistent Acidosis Indicates

                      bull Continued bleeding

                      bull Inadequate resuscitation

                      bull Myocardial dysfunction

                      dArr

                      serum pH (735 ndash 745)uArr

                      base deficit (2 to -2)uArr

                      serum lactate (04 ndash 18)

                      Base Deficit Categories

                      bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                      A base deficit of -6 is a marker of severeinjury amp significant mortality

                      Uses of Base Deficit in Trauma Care

                      bull Excellent correlation of base deficit to lactate and pH

                      bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                      bull Assessing shock and efficacy of resuscitation

                      bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                      Resuscitation End Points

                      bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                      ndash Mentation

                      ndash UO

                      ndash Labs base deficit serum lactate serum pH

                      Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                      urine output remain standard of carebull Uncompensated shock requires additional

                      resuscitationbull However after normalizing the above up to 85 of

                      severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                      bull Better markers of adequate resuscitation are needed

                      Goal Directed Therapy PEARLbull Recognize trouble

                      ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                      ndash Anticoagulantsndash Beta blockers

                      bull Early invasive monitoringbull Follow resuscitation goals

                      Optimizing Prehospital Resuscitation

                      bull Low volume fluid administration in penetrating injuries

                      bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                      sheetsbinderbull Tourniquetsbull Scoop and run transports

                      based on ldquogolden hourrdquo

                      ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                      bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                      bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                      Optimizing ResuscitationOptimizing Resuscitation

                      Prehospital Topicals 2010 Hemostatic Field Dressing

                      bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                      bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                      Tourniquets 2010

                      40

                      Indications for Tourniquetsbull Stop bleeding when life-

                      threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                      bull Stop bleeding with traumatic amputation

                      Intraosseous Infusion Devices 2010

                      EZ-IO

                      FAST1

                      Blood Substitutes 2010

                      bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                      bull Ready for prime time ndash not yet but soon - maybe

                      bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                      ndash JAMA - April 28 2008

                      Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                      bull Direct pressure to all external bleeding

                      bull Rapid suturing of all scalp and facial wounds

                      bull Rapid application of ThomasHare Traction splints for femur fx

                      bull Binder for pelvic fxbull Rapid reduction and pressure

                      dressings of mangled extremities

                      Pelvic Binders 2010

                      Optimizing ED Trauma Resuscitation (cont)

                      bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                      Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                      bull Use FAST to rapidly detect intra-abdominal fluid

                      bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                      floor during chest tube insertion

                      Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                      bull Intervene early in resuscitation to STOP bleeding

                      bull Conserve blood earlybull Aggressive rapid and efficient operative

                      interventionsbull Use novel methods to STOP bleeding in the

                      operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                      coagulopathy

                      bull Controversialndash Whether to administer type and how much

                      bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                      Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                      MTP Process Shands at UF

                      Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                      amp notifies designated RN

                      Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                      refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                      Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                      runner to BB with cross amp match

                      MTP runner delivers blood products to designated RN

                      Ismore MTPneeded

                      EDOR ICU

                      Designated RN assures bloodadministered per MD order

                      Designated RN assures blood administered per MD order

                      Designated RN sends MTP runner for more blood

                      MTP site

                      Ispt to be

                      transported withblood

                      Designated RN transportsblood with pt to location(ORICU)

                      END

                      END

                      END

                      YES NO

                      YES

                      NO

                      ED = Nurse ScribeOR = Circ RN notifies

                      Charge Nurse

                      62406

                      ED Thoracotomy for Moribund Patients

                      bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                      bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                      bull Aortic cross-clamping

                      Optimizing Resuscitation Across the Continuum

                      bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                      triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                      bullbull RegroupRegroup

                      Damage Control Focus on Physiology

                      bull Major paradigm shift in operative management of devastating injuries

                      bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                      temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                      ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                      Damage Control Patient Selectionbull Instability

                      bull Hypothermia (lt 34deg C)

                      bull Coagulopathy

                      bull Acidosis (pHlt 72BD -8)

                      bull Major traumaAvoid ldquoground zero of damage control

                      (physiological decompensation)

                      Neurological All unconscious trauma patients have brain injury until proven otherwise

                      bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                      bull Avoid hypotension in brain injured patients= poor outcome

                      bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                      bull Urgent CT and expert neurosurgical care is a must

                      Questions

                      Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                      Summary and Conclusionsbull It is truly all about the

                      patient

                      bull Team effort and framework is needed by design

                      bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                      bull Trauma centers save lives

                      • Welcome to Trauma Tracks
                      • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                      • OBJECTIVES
                      • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                      • Current Outcomes for CY 2009
                      • FRAMEWORK
                      • ProfileCredentials of a Trauma Patient
                      • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                      • FrameworkConsistent organization and clear cut communication produces effective outcomes
                      • Slide Number 10
                      • Slide Number 11
                      • Slide Number 12
                      • Slide Number 13
                      • Situation Awareness
                      • Most Potentially Preventable Trauma Deaths are related to
                      • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                      • Optimizing Resuscitation Across the Continuum
                      • Airway All trauma patients need oxygen until proven otherwise
                      • Airway All unstable trauma patients need a definitive airway
                      • Prehospital Intubation
                      • Prehospital Intubation
                      • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                      • Bridge Devices 2010
                      • Breathing All trauma patients need oxygen until proven otherwise
                      • CT Scan for thoracic trauma
                      • Hemorrhage All trauma patients are bleeding until proven otherwise
                      • Hemorrhage PEARL
                      • Hemorrhage 5 Anatomic Areas of Origin
                      • Hemorrhage Importance of Lactate amp BD
                      • Persistent Acidosis Indicates
                      • Base Deficit Categories
                      • Uses of Base Deficit in Trauma Care
                      • Resuscitation End Points
                      • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                      • Goal Directed Therapy PEARL
                      • Optimizing Prehospital Resuscitation
                      • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                      • PrehospitalTopicals 2010Hemostatic Field Dressing
                      • Tourniquets 2010
                      • Indications for Tourniquets
                      • Intraosseous Infusion Devices 2010
                      • Blood Substitutes 2010
                      • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                      • Pelvic Binders 2010
                      • Optimizing ED Trauma Resuscitation (cont)
                      • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                      • Slide Number 47
                      • Slide Number 48
                      • ED Thoracotomy for Moribund Patients
                      • Optimizing Resuscitation Across the Continuum
                      • Damage ControlFocus on Physiology
                      • Damage Control Patient Selection
                      • Neurological All unconscious trauma patients have brain injury until proven otherwise
                      • Questions
                      • Summary and Conclusions

                        Alberta-- first trauma alert

                        Situation Awareness

                        Detection(Perception)

                        Patient

                        Team

                        Environment

                        Tools

                        Diagnosis

                        Prediction

                        PremiseCause of instability must be

                        recognized and corrected quickly by using a systematic approach

                        It is important to identify and prioritize systemic compromise

                        Most Potentially Preventable Trauma Deaths are related to

                        bull Airway obstruction

                        bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

                        Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

                        1 All trauma patients need oxygen until proven otherwise

                        2 All trauma patients are bleeding until proven otherwise

                        3 All trauma patients have a cervical spine injury until proven otherwise

                        4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

                        Optimizing Resuscitation Across the Continuum

                        bull Prehospital Phasendash Key patient

                        information must be communicated

                        bull Mechanismbull GCSbull Vital Signsbull Interventions

                        ndash Be familiar with modalities and controversies

                        Pay attention to episodic events of hypotension

                        Airway All trauma patients need oxygen until proven otherwise

                        bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

                        bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

                        bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

                        Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                        unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                        of breathingmaximizes O2 delivery

                        ndash Corrects acid base disturbances

                        ndash Allow clinician to focus on other life-threatening issues

                        Prehospital Intubation

                        bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                        bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                        Prehospital Intubation

                        bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                        bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                        bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                        The impact of prehospital ventilation on outcome after severe traumatic brain injury

                        Cusheri et al JTrauma 2007 Jun62(6)1330-6

                        BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                        determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                        impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                        with lower mortality after severe TBI

                        Bridge Devices 2010

                        LMAKing Airway

                        Combitube

                        Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                        25 of all trauma deathsbull Understand the significance of

                        patternsndash 1st and 2nd rib fxs abdominal breathing

                        bull Treat the pneumo before ETTbull Life-threatening thoracic

                        injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                        1

                        2

                        CT Scan for thoracic trauma

                        An occult pneumothorax seen on a CT scan that was not detected on a plain

                        anteroposterior supine chest radiograph

                        bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                        bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                        Hemorrhage All trauma patients are bleeding until proven otherwise

                        bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                        bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                        bull Prevent shock by arresting the bleeding

                        bull Mandates the earliest possible ldquogoal directed therapyrdquo

                        Hemorrhage PEARLbull Recognize trouble

                        ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                        increases morbidity and doubles mortality especially in head injured patients

                        bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                        ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                        Hemorrhage 5 Anatomic Areas of Origin

                        Kirkpatrick AW et al Can J Surg 200851(1)57-69

                        Hemorrhage Importance of Lactate amp BD

                        bull For Resuscitation to Occurndash Adequate perfusion and

                        ndash Tissue oxygenation must be restored

                        bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                        ndash Controlling the bleeding

                        Persistent Acidosis Indicates

                        bull Continued bleeding

                        bull Inadequate resuscitation

                        bull Myocardial dysfunction

                        dArr

                        serum pH (735 ndash 745)uArr

                        base deficit (2 to -2)uArr

                        serum lactate (04 ndash 18)

                        Base Deficit Categories

                        bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                        A base deficit of -6 is a marker of severeinjury amp significant mortality

                        Uses of Base Deficit in Trauma Care

                        bull Excellent correlation of base deficit to lactate and pH

                        bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                        bull Assessing shock and efficacy of resuscitation

                        bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                        Resuscitation End Points

                        bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                        ndash Mentation

                        ndash UO

                        ndash Labs base deficit serum lactate serum pH

                        Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                        urine output remain standard of carebull Uncompensated shock requires additional

                        resuscitationbull However after normalizing the above up to 85 of

                        severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                        bull Better markers of adequate resuscitation are needed

                        Goal Directed Therapy PEARLbull Recognize trouble

                        ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                        ndash Anticoagulantsndash Beta blockers

                        bull Early invasive monitoringbull Follow resuscitation goals

                        Optimizing Prehospital Resuscitation

                        bull Low volume fluid administration in penetrating injuries

                        bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                        sheetsbinderbull Tourniquetsbull Scoop and run transports

                        based on ldquogolden hourrdquo

                        ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                        bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                        bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                        Optimizing ResuscitationOptimizing Resuscitation

                        Prehospital Topicals 2010 Hemostatic Field Dressing

                        bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                        bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                        Tourniquets 2010

                        40

                        Indications for Tourniquetsbull Stop bleeding when life-

                        threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                        bull Stop bleeding with traumatic amputation

                        Intraosseous Infusion Devices 2010

                        EZ-IO

                        FAST1

                        Blood Substitutes 2010

                        bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                        bull Ready for prime time ndash not yet but soon - maybe

                        bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                        ndash JAMA - April 28 2008

                        Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                        bull Direct pressure to all external bleeding

                        bull Rapid suturing of all scalp and facial wounds

                        bull Rapid application of ThomasHare Traction splints for femur fx

                        bull Binder for pelvic fxbull Rapid reduction and pressure

                        dressings of mangled extremities

                        Pelvic Binders 2010

                        Optimizing ED Trauma Resuscitation (cont)

                        bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                        Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                        bull Use FAST to rapidly detect intra-abdominal fluid

                        bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                        floor during chest tube insertion

                        Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                        bull Intervene early in resuscitation to STOP bleeding

                        bull Conserve blood earlybull Aggressive rapid and efficient operative

                        interventionsbull Use novel methods to STOP bleeding in the

                        operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                        coagulopathy

                        bull Controversialndash Whether to administer type and how much

                        bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                        Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                        MTP Process Shands at UF

                        Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                        amp notifies designated RN

                        Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                        refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                        Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                        runner to BB with cross amp match

                        MTP runner delivers blood products to designated RN

                        Ismore MTPneeded

                        EDOR ICU

                        Designated RN assures bloodadministered per MD order

                        Designated RN assures blood administered per MD order

                        Designated RN sends MTP runner for more blood

                        MTP site

                        Ispt to be

                        transported withblood

                        Designated RN transportsblood with pt to location(ORICU)

                        END

                        END

                        END

                        YES NO

                        YES

                        NO

                        ED = Nurse ScribeOR = Circ RN notifies

                        Charge Nurse

                        62406

                        ED Thoracotomy for Moribund Patients

                        bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                        bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                        bull Aortic cross-clamping

                        Optimizing Resuscitation Across the Continuum

                        bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                        triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                        bullbull RegroupRegroup

                        Damage Control Focus on Physiology

                        bull Major paradigm shift in operative management of devastating injuries

                        bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                        temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                        ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                        Damage Control Patient Selectionbull Instability

                        bull Hypothermia (lt 34deg C)

                        bull Coagulopathy

                        bull Acidosis (pHlt 72BD -8)

                        bull Major traumaAvoid ldquoground zero of damage control

                        (physiological decompensation)

                        Neurological All unconscious trauma patients have brain injury until proven otherwise

                        bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                        bull Avoid hypotension in brain injured patients= poor outcome

                        bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                        bull Urgent CT and expert neurosurgical care is a must

                        Questions

                        Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                        Summary and Conclusionsbull It is truly all about the

                        patient

                        bull Team effort and framework is needed by design

                        bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                        bull Trauma centers save lives

                        • Welcome to Trauma Tracks
                        • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                        • OBJECTIVES
                        • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                        • Current Outcomes for CY 2009
                        • FRAMEWORK
                        • ProfileCredentials of a Trauma Patient
                        • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                        • FrameworkConsistent organization and clear cut communication produces effective outcomes
                        • Slide Number 10
                        • Slide Number 11
                        • Slide Number 12
                        • Slide Number 13
                        • Situation Awareness
                        • Most Potentially Preventable Trauma Deaths are related to
                        • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                        • Optimizing Resuscitation Across the Continuum
                        • Airway All trauma patients need oxygen until proven otherwise
                        • Airway All unstable trauma patients need a definitive airway
                        • Prehospital Intubation
                        • Prehospital Intubation
                        • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                        • Bridge Devices 2010
                        • Breathing All trauma patients need oxygen until proven otherwise
                        • CT Scan for thoracic trauma
                        • Hemorrhage All trauma patients are bleeding until proven otherwise
                        • Hemorrhage PEARL
                        • Hemorrhage 5 Anatomic Areas of Origin
                        • Hemorrhage Importance of Lactate amp BD
                        • Persistent Acidosis Indicates
                        • Base Deficit Categories
                        • Uses of Base Deficit in Trauma Care
                        • Resuscitation End Points
                        • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                        • Goal Directed Therapy PEARL
                        • Optimizing Prehospital Resuscitation
                        • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                        • PrehospitalTopicals 2010Hemostatic Field Dressing
                        • Tourniquets 2010
                        • Indications for Tourniquets
                        • Intraosseous Infusion Devices 2010
                        • Blood Substitutes 2010
                        • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                        • Pelvic Binders 2010
                        • Optimizing ED Trauma Resuscitation (cont)
                        • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                        • Slide Number 47
                        • Slide Number 48
                        • ED Thoracotomy for Moribund Patients
                        • Optimizing Resuscitation Across the Continuum
                        • Damage ControlFocus on Physiology
                        • Damage Control Patient Selection
                        • Neurological All unconscious trauma patients have brain injury until proven otherwise
                        • Questions
                        • Summary and Conclusions

                          Situation Awareness

                          Detection(Perception)

                          Patient

                          Team

                          Environment

                          Tools

                          Diagnosis

                          Prediction

                          PremiseCause of instability must be

                          recognized and corrected quickly by using a systematic approach

                          It is important to identify and prioritize systemic compromise

                          Most Potentially Preventable Trauma Deaths are related to

                          bull Airway obstruction

                          bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

                          Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

                          1 All trauma patients need oxygen until proven otherwise

                          2 All trauma patients are bleeding until proven otherwise

                          3 All trauma patients have a cervical spine injury until proven otherwise

                          4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

                          Optimizing Resuscitation Across the Continuum

                          bull Prehospital Phasendash Key patient

                          information must be communicated

                          bull Mechanismbull GCSbull Vital Signsbull Interventions

                          ndash Be familiar with modalities and controversies

                          Pay attention to episodic events of hypotension

                          Airway All trauma patients need oxygen until proven otherwise

                          bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

                          bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

                          bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

                          Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                          unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                          of breathingmaximizes O2 delivery

                          ndash Corrects acid base disturbances

                          ndash Allow clinician to focus on other life-threatening issues

                          Prehospital Intubation

                          bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                          bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                          Prehospital Intubation

                          bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                          bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                          bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                          The impact of prehospital ventilation on outcome after severe traumatic brain injury

                          Cusheri et al JTrauma 2007 Jun62(6)1330-6

                          BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                          determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                          impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                          with lower mortality after severe TBI

                          Bridge Devices 2010

                          LMAKing Airway

                          Combitube

                          Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                          25 of all trauma deathsbull Understand the significance of

                          patternsndash 1st and 2nd rib fxs abdominal breathing

                          bull Treat the pneumo before ETTbull Life-threatening thoracic

                          injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                          1

                          2

                          CT Scan for thoracic trauma

                          An occult pneumothorax seen on a CT scan that was not detected on a plain

                          anteroposterior supine chest radiograph

                          bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                          bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                          Hemorrhage All trauma patients are bleeding until proven otherwise

                          bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                          bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                          bull Prevent shock by arresting the bleeding

                          bull Mandates the earliest possible ldquogoal directed therapyrdquo

                          Hemorrhage PEARLbull Recognize trouble

                          ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                          increases morbidity and doubles mortality especially in head injured patients

                          bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                          ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                          Hemorrhage 5 Anatomic Areas of Origin

                          Kirkpatrick AW et al Can J Surg 200851(1)57-69

                          Hemorrhage Importance of Lactate amp BD

                          bull For Resuscitation to Occurndash Adequate perfusion and

                          ndash Tissue oxygenation must be restored

                          bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                          ndash Controlling the bleeding

                          Persistent Acidosis Indicates

                          bull Continued bleeding

                          bull Inadequate resuscitation

                          bull Myocardial dysfunction

                          dArr

                          serum pH (735 ndash 745)uArr

                          base deficit (2 to -2)uArr

                          serum lactate (04 ndash 18)

                          Base Deficit Categories

                          bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                          A base deficit of -6 is a marker of severeinjury amp significant mortality

                          Uses of Base Deficit in Trauma Care

                          bull Excellent correlation of base deficit to lactate and pH

                          bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                          bull Assessing shock and efficacy of resuscitation

                          bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                          Resuscitation End Points

                          bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                          ndash Mentation

                          ndash UO

                          ndash Labs base deficit serum lactate serum pH

                          Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                          urine output remain standard of carebull Uncompensated shock requires additional

                          resuscitationbull However after normalizing the above up to 85 of

                          severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                          bull Better markers of adequate resuscitation are needed

                          Goal Directed Therapy PEARLbull Recognize trouble

                          ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                          ndash Anticoagulantsndash Beta blockers

                          bull Early invasive monitoringbull Follow resuscitation goals

                          Optimizing Prehospital Resuscitation

                          bull Low volume fluid administration in penetrating injuries

                          bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                          sheetsbinderbull Tourniquetsbull Scoop and run transports

                          based on ldquogolden hourrdquo

                          ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                          bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                          bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                          Optimizing ResuscitationOptimizing Resuscitation

                          Prehospital Topicals 2010 Hemostatic Field Dressing

                          bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                          bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                          Tourniquets 2010

                          40

                          Indications for Tourniquetsbull Stop bleeding when life-

                          threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                          bull Stop bleeding with traumatic amputation

                          Intraosseous Infusion Devices 2010

                          EZ-IO

                          FAST1

                          Blood Substitutes 2010

                          bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                          bull Ready for prime time ndash not yet but soon - maybe

                          bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                          ndash JAMA - April 28 2008

                          Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                          bull Direct pressure to all external bleeding

                          bull Rapid suturing of all scalp and facial wounds

                          bull Rapid application of ThomasHare Traction splints for femur fx

                          bull Binder for pelvic fxbull Rapid reduction and pressure

                          dressings of mangled extremities

                          Pelvic Binders 2010

                          Optimizing ED Trauma Resuscitation (cont)

                          bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                          Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                          bull Use FAST to rapidly detect intra-abdominal fluid

                          bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                          floor during chest tube insertion

                          Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                          bull Intervene early in resuscitation to STOP bleeding

                          bull Conserve blood earlybull Aggressive rapid and efficient operative

                          interventionsbull Use novel methods to STOP bleeding in the

                          operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                          coagulopathy

                          bull Controversialndash Whether to administer type and how much

                          bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                          Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                          MTP Process Shands at UF

                          Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                          amp notifies designated RN

                          Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                          refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                          Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                          runner to BB with cross amp match

                          MTP runner delivers blood products to designated RN

                          Ismore MTPneeded

                          EDOR ICU

                          Designated RN assures bloodadministered per MD order

                          Designated RN assures blood administered per MD order

                          Designated RN sends MTP runner for more blood

                          MTP site

                          Ispt to be

                          transported withblood

                          Designated RN transportsblood with pt to location(ORICU)

                          END

                          END

                          END

                          YES NO

                          YES

                          NO

                          ED = Nurse ScribeOR = Circ RN notifies

                          Charge Nurse

                          62406

                          ED Thoracotomy for Moribund Patients

                          bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                          bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                          bull Aortic cross-clamping

                          Optimizing Resuscitation Across the Continuum

                          bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                          triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                          bullbull RegroupRegroup

                          Damage Control Focus on Physiology

                          bull Major paradigm shift in operative management of devastating injuries

                          bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                          temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                          ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                          Damage Control Patient Selectionbull Instability

                          bull Hypothermia (lt 34deg C)

                          bull Coagulopathy

                          bull Acidosis (pHlt 72BD -8)

                          bull Major traumaAvoid ldquoground zero of damage control

                          (physiological decompensation)

                          Neurological All unconscious trauma patients have brain injury until proven otherwise

                          bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                          bull Avoid hypotension in brain injured patients= poor outcome

                          bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                          bull Urgent CT and expert neurosurgical care is a must

                          Questions

                          Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                          Summary and Conclusionsbull It is truly all about the

                          patient

                          bull Team effort and framework is needed by design

                          bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                          bull Trauma centers save lives

                          • Welcome to Trauma Tracks
                          • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                          • OBJECTIVES
                          • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                          • Current Outcomes for CY 2009
                          • FRAMEWORK
                          • ProfileCredentials of a Trauma Patient
                          • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                          • FrameworkConsistent organization and clear cut communication produces effective outcomes
                          • Slide Number 10
                          • Slide Number 11
                          • Slide Number 12
                          • Slide Number 13
                          • Situation Awareness
                          • Most Potentially Preventable Trauma Deaths are related to
                          • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                          • Optimizing Resuscitation Across the Continuum
                          • Airway All trauma patients need oxygen until proven otherwise
                          • Airway All unstable trauma patients need a definitive airway
                          • Prehospital Intubation
                          • Prehospital Intubation
                          • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                          • Bridge Devices 2010
                          • Breathing All trauma patients need oxygen until proven otherwise
                          • CT Scan for thoracic trauma
                          • Hemorrhage All trauma patients are bleeding until proven otherwise
                          • Hemorrhage PEARL
                          • Hemorrhage 5 Anatomic Areas of Origin
                          • Hemorrhage Importance of Lactate amp BD
                          • Persistent Acidosis Indicates
                          • Base Deficit Categories
                          • Uses of Base Deficit in Trauma Care
                          • Resuscitation End Points
                          • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                          • Goal Directed Therapy PEARL
                          • Optimizing Prehospital Resuscitation
                          • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                          • PrehospitalTopicals 2010Hemostatic Field Dressing
                          • Tourniquets 2010
                          • Indications for Tourniquets
                          • Intraosseous Infusion Devices 2010
                          • Blood Substitutes 2010
                          • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                          • Pelvic Binders 2010
                          • Optimizing ED Trauma Resuscitation (cont)
                          • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                          • Slide Number 47
                          • Slide Number 48
                          • ED Thoracotomy for Moribund Patients
                          • Optimizing Resuscitation Across the Continuum
                          • Damage ControlFocus on Physiology
                          • Damage Control Patient Selection
                          • Neurological All unconscious trauma patients have brain injury until proven otherwise
                          • Questions
                          • Summary and Conclusions

                            Most Potentially Preventable Trauma Deaths are related to

                            bull Airway obstruction

                            bull Hemorrhagendash Hemopneumothoraxndash Intracavitary bleedingndash Intracranial hemorrhage

                            Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

                            1 All trauma patients need oxygen until proven otherwise

                            2 All trauma patients are bleeding until proven otherwise

                            3 All trauma patients have a cervical spine injury until proven otherwise

                            4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

                            Optimizing Resuscitation Across the Continuum

                            bull Prehospital Phasendash Key patient

                            information must be communicated

                            bull Mechanismbull GCSbull Vital Signsbull Interventions

                            ndash Be familiar with modalities and controversies

                            Pay attention to episodic events of hypotension

                            Airway All trauma patients need oxygen until proven otherwise

                            bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

                            bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

                            bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

                            Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                            unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                            of breathingmaximizes O2 delivery

                            ndash Corrects acid base disturbances

                            ndash Allow clinician to focus on other life-threatening issues

                            Prehospital Intubation

                            bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                            bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                            Prehospital Intubation

                            bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                            bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                            bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                            The impact of prehospital ventilation on outcome after severe traumatic brain injury

                            Cusheri et al JTrauma 2007 Jun62(6)1330-6

                            BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                            determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                            impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                            with lower mortality after severe TBI

                            Bridge Devices 2010

                            LMAKing Airway

                            Combitube

                            Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                            25 of all trauma deathsbull Understand the significance of

                            patternsndash 1st and 2nd rib fxs abdominal breathing

                            bull Treat the pneumo before ETTbull Life-threatening thoracic

                            injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                            1

                            2

                            CT Scan for thoracic trauma

                            An occult pneumothorax seen on a CT scan that was not detected on a plain

                            anteroposterior supine chest radiograph

                            bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                            bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                            Hemorrhage All trauma patients are bleeding until proven otherwise

                            bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                            bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                            bull Prevent shock by arresting the bleeding

                            bull Mandates the earliest possible ldquogoal directed therapyrdquo

                            Hemorrhage PEARLbull Recognize trouble

                            ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                            increases morbidity and doubles mortality especially in head injured patients

                            bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                            ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                            Hemorrhage 5 Anatomic Areas of Origin

                            Kirkpatrick AW et al Can J Surg 200851(1)57-69

                            Hemorrhage Importance of Lactate amp BD

                            bull For Resuscitation to Occurndash Adequate perfusion and

                            ndash Tissue oxygenation must be restored

                            bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                            ndash Controlling the bleeding

                            Persistent Acidosis Indicates

                            bull Continued bleeding

                            bull Inadequate resuscitation

                            bull Myocardial dysfunction

                            dArr

                            serum pH (735 ndash 745)uArr

                            base deficit (2 to -2)uArr

                            serum lactate (04 ndash 18)

                            Base Deficit Categories

                            bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                            A base deficit of -6 is a marker of severeinjury amp significant mortality

                            Uses of Base Deficit in Trauma Care

                            bull Excellent correlation of base deficit to lactate and pH

                            bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                            bull Assessing shock and efficacy of resuscitation

                            bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                            Resuscitation End Points

                            bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                            ndash Mentation

                            ndash UO

                            ndash Labs base deficit serum lactate serum pH

                            Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                            urine output remain standard of carebull Uncompensated shock requires additional

                            resuscitationbull However after normalizing the above up to 85 of

                            severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                            bull Better markers of adequate resuscitation are needed

                            Goal Directed Therapy PEARLbull Recognize trouble

                            ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                            ndash Anticoagulantsndash Beta blockers

                            bull Early invasive monitoringbull Follow resuscitation goals

                            Optimizing Prehospital Resuscitation

                            bull Low volume fluid administration in penetrating injuries

                            bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                            sheetsbinderbull Tourniquetsbull Scoop and run transports

                            based on ldquogolden hourrdquo

                            ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                            bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                            bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                            Optimizing ResuscitationOptimizing Resuscitation

                            Prehospital Topicals 2010 Hemostatic Field Dressing

                            bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                            bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                            Tourniquets 2010

                            40

                            Indications for Tourniquetsbull Stop bleeding when life-

                            threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                            bull Stop bleeding with traumatic amputation

                            Intraosseous Infusion Devices 2010

                            EZ-IO

                            FAST1

                            Blood Substitutes 2010

                            bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                            bull Ready for prime time ndash not yet but soon - maybe

                            bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                            ndash JAMA - April 28 2008

                            Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                            bull Direct pressure to all external bleeding

                            bull Rapid suturing of all scalp and facial wounds

                            bull Rapid application of ThomasHare Traction splints for femur fx

                            bull Binder for pelvic fxbull Rapid reduction and pressure

                            dressings of mangled extremities

                            Pelvic Binders 2010

                            Optimizing ED Trauma Resuscitation (cont)

                            bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                            Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                            bull Use FAST to rapidly detect intra-abdominal fluid

                            bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                            floor during chest tube insertion

                            Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                            bull Intervene early in resuscitation to STOP bleeding

                            bull Conserve blood earlybull Aggressive rapid and efficient operative

                            interventionsbull Use novel methods to STOP bleeding in the

                            operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                            coagulopathy

                            bull Controversialndash Whether to administer type and how much

                            bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                            Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                            MTP Process Shands at UF

                            Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                            amp notifies designated RN

                            Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                            refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                            Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                            runner to BB with cross amp match

                            MTP runner delivers blood products to designated RN

                            Ismore MTPneeded

                            EDOR ICU

                            Designated RN assures bloodadministered per MD order

                            Designated RN assures blood administered per MD order

                            Designated RN sends MTP runner for more blood

                            MTP site

                            Ispt to be

                            transported withblood

                            Designated RN transportsblood with pt to location(ORICU)

                            END

                            END

                            END

                            YES NO

                            YES

                            NO

                            ED = Nurse ScribeOR = Circ RN notifies

                            Charge Nurse

                            62406

                            ED Thoracotomy for Moribund Patients

                            bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                            bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                            bull Aortic cross-clamping

                            Optimizing Resuscitation Across the Continuum

                            bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                            triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                            bullbull RegroupRegroup

                            Damage Control Focus on Physiology

                            bull Major paradigm shift in operative management of devastating injuries

                            bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                            temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                            ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                            Damage Control Patient Selectionbull Instability

                            bull Hypothermia (lt 34deg C)

                            bull Coagulopathy

                            bull Acidosis (pHlt 72BD -8)

                            bull Major traumaAvoid ldquoground zero of damage control

                            (physiological decompensation)

                            Neurological All unconscious trauma patients have brain injury until proven otherwise

                            bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                            bull Avoid hypotension in brain injured patients= poor outcome

                            bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                            bull Urgent CT and expert neurosurgical care is a must

                            Questions

                            Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                            Summary and Conclusionsbull It is truly all about the

                            patient

                            bull Team effort and framework is needed by design

                            bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                            bull Trauma centers save lives

                            • Welcome to Trauma Tracks
                            • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                            • OBJECTIVES
                            • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                            • Current Outcomes for CY 2009
                            • FRAMEWORK
                            • ProfileCredentials of a Trauma Patient
                            • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                            • FrameworkConsistent organization and clear cut communication produces effective outcomes
                            • Slide Number 10
                            • Slide Number 11
                            • Slide Number 12
                            • Slide Number 13
                            • Situation Awareness
                            • Most Potentially Preventable Trauma Deaths are related to
                            • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                            • Optimizing Resuscitation Across the Continuum
                            • Airway All trauma patients need oxygen until proven otherwise
                            • Airway All unstable trauma patients need a definitive airway
                            • Prehospital Intubation
                            • Prehospital Intubation
                            • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                            • Bridge Devices 2010
                            • Breathing All trauma patients need oxygen until proven otherwise
                            • CT Scan for thoracic trauma
                            • Hemorrhage All trauma patients are bleeding until proven otherwise
                            • Hemorrhage PEARL
                            • Hemorrhage 5 Anatomic Areas of Origin
                            • Hemorrhage Importance of Lactate amp BD
                            • Persistent Acidosis Indicates
                            • Base Deficit Categories
                            • Uses of Base Deficit in Trauma Care
                            • Resuscitation End Points
                            • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                            • Goal Directed Therapy PEARL
                            • Optimizing Prehospital Resuscitation
                            • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                            • PrehospitalTopicals 2010Hemostatic Field Dressing
                            • Tourniquets 2010
                            • Indications for Tourniquets
                            • Intraosseous Infusion Devices 2010
                            • Blood Substitutes 2010
                            • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                            • Pelvic Binders 2010
                            • Optimizing ED Trauma Resuscitation (cont)
                            • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                            • Slide Number 47
                            • Slide Number 48
                            • ED Thoracotomy for Moribund Patients
                            • Optimizing Resuscitation Across the Continuum
                            • Damage ControlFocus on Physiology
                            • Damage Control Patient Selection
                            • Neurological All unconscious trauma patients have brain injury until proven otherwise
                            • Questions
                            • Summary and Conclusions

                              Framework We all need to know our A B C Ds ldquoGolden Rulesrdquo of Trauma

                              1 All trauma patients need oxygen until proven otherwise

                              2 All trauma patients are bleeding until proven otherwise

                              3 All trauma patients have a cervical spine injury until proven otherwise

                              4 All unconsciousaltered LOC trauma patients have a brain injury until proven otherwise

                              Optimizing Resuscitation Across the Continuum

                              bull Prehospital Phasendash Key patient

                              information must be communicated

                              bull Mechanismbull GCSbull Vital Signsbull Interventions

                              ndash Be familiar with modalities and controversies

                              Pay attention to episodic events of hypotension

                              Airway All trauma patients need oxygen until proven otherwise

                              bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

                              bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

                              bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

                              Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                              unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                              of breathingmaximizes O2 delivery

                              ndash Corrects acid base disturbances

                              ndash Allow clinician to focus on other life-threatening issues

                              Prehospital Intubation

                              bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                              bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                              Prehospital Intubation

                              bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                              bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                              bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                              The impact of prehospital ventilation on outcome after severe traumatic brain injury

                              Cusheri et al JTrauma 2007 Jun62(6)1330-6

                              BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                              determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                              impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                              with lower mortality after severe TBI

                              Bridge Devices 2010

                              LMAKing Airway

                              Combitube

                              Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                              25 of all trauma deathsbull Understand the significance of

                              patternsndash 1st and 2nd rib fxs abdominal breathing

                              bull Treat the pneumo before ETTbull Life-threatening thoracic

                              injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                              1

                              2

                              CT Scan for thoracic trauma

                              An occult pneumothorax seen on a CT scan that was not detected on a plain

                              anteroposterior supine chest radiograph

                              bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                              bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                              Hemorrhage All trauma patients are bleeding until proven otherwise

                              bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                              bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                              bull Prevent shock by arresting the bleeding

                              bull Mandates the earliest possible ldquogoal directed therapyrdquo

                              Hemorrhage PEARLbull Recognize trouble

                              ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                              increases morbidity and doubles mortality especially in head injured patients

                              bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                              ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                              Hemorrhage 5 Anatomic Areas of Origin

                              Kirkpatrick AW et al Can J Surg 200851(1)57-69

                              Hemorrhage Importance of Lactate amp BD

                              bull For Resuscitation to Occurndash Adequate perfusion and

                              ndash Tissue oxygenation must be restored

                              bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                              ndash Controlling the bleeding

                              Persistent Acidosis Indicates

                              bull Continued bleeding

                              bull Inadequate resuscitation

                              bull Myocardial dysfunction

                              dArr

                              serum pH (735 ndash 745)uArr

                              base deficit (2 to -2)uArr

                              serum lactate (04 ndash 18)

                              Base Deficit Categories

                              bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                              A base deficit of -6 is a marker of severeinjury amp significant mortality

                              Uses of Base Deficit in Trauma Care

                              bull Excellent correlation of base deficit to lactate and pH

                              bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                              bull Assessing shock and efficacy of resuscitation

                              bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                              Resuscitation End Points

                              bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                              ndash Mentation

                              ndash UO

                              ndash Labs base deficit serum lactate serum pH

                              Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                              urine output remain standard of carebull Uncompensated shock requires additional

                              resuscitationbull However after normalizing the above up to 85 of

                              severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                              bull Better markers of adequate resuscitation are needed

                              Goal Directed Therapy PEARLbull Recognize trouble

                              ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                              ndash Anticoagulantsndash Beta blockers

                              bull Early invasive monitoringbull Follow resuscitation goals

                              Optimizing Prehospital Resuscitation

                              bull Low volume fluid administration in penetrating injuries

                              bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                              sheetsbinderbull Tourniquetsbull Scoop and run transports

                              based on ldquogolden hourrdquo

                              ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                              bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                              bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                              Optimizing ResuscitationOptimizing Resuscitation

                              Prehospital Topicals 2010 Hemostatic Field Dressing

                              bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                              bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                              Tourniquets 2010

                              40

                              Indications for Tourniquetsbull Stop bleeding when life-

                              threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                              bull Stop bleeding with traumatic amputation

                              Intraosseous Infusion Devices 2010

                              EZ-IO

                              FAST1

                              Blood Substitutes 2010

                              bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                              bull Ready for prime time ndash not yet but soon - maybe

                              bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                              ndash JAMA - April 28 2008

                              Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                              bull Direct pressure to all external bleeding

                              bull Rapid suturing of all scalp and facial wounds

                              bull Rapid application of ThomasHare Traction splints for femur fx

                              bull Binder for pelvic fxbull Rapid reduction and pressure

                              dressings of mangled extremities

                              Pelvic Binders 2010

                              Optimizing ED Trauma Resuscitation (cont)

                              bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                              Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                              bull Use FAST to rapidly detect intra-abdominal fluid

                              bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                              floor during chest tube insertion

                              Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                              bull Intervene early in resuscitation to STOP bleeding

                              bull Conserve blood earlybull Aggressive rapid and efficient operative

                              interventionsbull Use novel methods to STOP bleeding in the

                              operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                              coagulopathy

                              bull Controversialndash Whether to administer type and how much

                              bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                              Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                              MTP Process Shands at UF

                              Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                              amp notifies designated RN

                              Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                              refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                              Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                              runner to BB with cross amp match

                              MTP runner delivers blood products to designated RN

                              Ismore MTPneeded

                              EDOR ICU

                              Designated RN assures bloodadministered per MD order

                              Designated RN assures blood administered per MD order

                              Designated RN sends MTP runner for more blood

                              MTP site

                              Ispt to be

                              transported withblood

                              Designated RN transportsblood with pt to location(ORICU)

                              END

                              END

                              END

                              YES NO

                              YES

                              NO

                              ED = Nurse ScribeOR = Circ RN notifies

                              Charge Nurse

                              62406

                              ED Thoracotomy for Moribund Patients

                              bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                              bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                              bull Aortic cross-clamping

                              Optimizing Resuscitation Across the Continuum

                              bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                              triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                              bullbull RegroupRegroup

                              Damage Control Focus on Physiology

                              bull Major paradigm shift in operative management of devastating injuries

                              bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                              temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                              ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                              Damage Control Patient Selectionbull Instability

                              bull Hypothermia (lt 34deg C)

                              bull Coagulopathy

                              bull Acidosis (pHlt 72BD -8)

                              bull Major traumaAvoid ldquoground zero of damage control

                              (physiological decompensation)

                              Neurological All unconscious trauma patients have brain injury until proven otherwise

                              bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                              bull Avoid hypotension in brain injured patients= poor outcome

                              bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                              bull Urgent CT and expert neurosurgical care is a must

                              Questions

                              Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                              Summary and Conclusionsbull It is truly all about the

                              patient

                              bull Team effort and framework is needed by design

                              bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                              bull Trauma centers save lives

                              • Welcome to Trauma Tracks
                              • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                              • OBJECTIVES
                              • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                              • Current Outcomes for CY 2009
                              • FRAMEWORK
                              • ProfileCredentials of a Trauma Patient
                              • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                              • FrameworkConsistent organization and clear cut communication produces effective outcomes
                              • Slide Number 10
                              • Slide Number 11
                              • Slide Number 12
                              • Slide Number 13
                              • Situation Awareness
                              • Most Potentially Preventable Trauma Deaths are related to
                              • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                              • Optimizing Resuscitation Across the Continuum
                              • Airway All trauma patients need oxygen until proven otherwise
                              • Airway All unstable trauma patients need a definitive airway
                              • Prehospital Intubation
                              • Prehospital Intubation
                              • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                              • Bridge Devices 2010
                              • Breathing All trauma patients need oxygen until proven otherwise
                              • CT Scan for thoracic trauma
                              • Hemorrhage All trauma patients are bleeding until proven otherwise
                              • Hemorrhage PEARL
                              • Hemorrhage 5 Anatomic Areas of Origin
                              • Hemorrhage Importance of Lactate amp BD
                              • Persistent Acidosis Indicates
                              • Base Deficit Categories
                              • Uses of Base Deficit in Trauma Care
                              • Resuscitation End Points
                              • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                              • Goal Directed Therapy PEARL
                              • Optimizing Prehospital Resuscitation
                              • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                              • PrehospitalTopicals 2010Hemostatic Field Dressing
                              • Tourniquets 2010
                              • Indications for Tourniquets
                              • Intraosseous Infusion Devices 2010
                              • Blood Substitutes 2010
                              • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                              • Pelvic Binders 2010
                              • Optimizing ED Trauma Resuscitation (cont)
                              • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                              • Slide Number 47
                              • Slide Number 48
                              • ED Thoracotomy for Moribund Patients
                              • Optimizing Resuscitation Across the Continuum
                              • Damage ControlFocus on Physiology
                              • Damage Control Patient Selection
                              • Neurological All unconscious trauma patients have brain injury until proven otherwise
                              • Questions
                              • Summary and Conclusions

                                Optimizing Resuscitation Across the Continuum

                                bull Prehospital Phasendash Key patient

                                information must be communicated

                                bull Mechanismbull GCSbull Vital Signsbull Interventions

                                ndash Be familiar with modalities and controversies

                                Pay attention to episodic events of hypotension

                                Airway All trauma patients need oxygen until proven otherwise

                                bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

                                bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

                                bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

                                Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                                unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                                of breathingmaximizes O2 delivery

                                ndash Corrects acid base disturbances

                                ndash Allow clinician to focus on other life-threatening issues

                                Prehospital Intubation

                                bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                                bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                                Prehospital Intubation

                                bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                                bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                                bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                                The impact of prehospital ventilation on outcome after severe traumatic brain injury

                                Cusheri et al JTrauma 2007 Jun62(6)1330-6

                                BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                                determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                                impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                                with lower mortality after severe TBI

                                Bridge Devices 2010

                                LMAKing Airway

                                Combitube

                                Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                                25 of all trauma deathsbull Understand the significance of

                                patternsndash 1st and 2nd rib fxs abdominal breathing

                                bull Treat the pneumo before ETTbull Life-threatening thoracic

                                injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                                1

                                2

                                CT Scan for thoracic trauma

                                An occult pneumothorax seen on a CT scan that was not detected on a plain

                                anteroposterior supine chest radiograph

                                bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                                bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                                Hemorrhage All trauma patients are bleeding until proven otherwise

                                bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                                bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                                bull Prevent shock by arresting the bleeding

                                bull Mandates the earliest possible ldquogoal directed therapyrdquo

                                Hemorrhage PEARLbull Recognize trouble

                                ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                increases morbidity and doubles mortality especially in head injured patients

                                bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                Hemorrhage 5 Anatomic Areas of Origin

                                Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                Hemorrhage Importance of Lactate amp BD

                                bull For Resuscitation to Occurndash Adequate perfusion and

                                ndash Tissue oxygenation must be restored

                                bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                ndash Controlling the bleeding

                                Persistent Acidosis Indicates

                                bull Continued bleeding

                                bull Inadequate resuscitation

                                bull Myocardial dysfunction

                                dArr

                                serum pH (735 ndash 745)uArr

                                base deficit (2 to -2)uArr

                                serum lactate (04 ndash 18)

                                Base Deficit Categories

                                bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                A base deficit of -6 is a marker of severeinjury amp significant mortality

                                Uses of Base Deficit in Trauma Care

                                bull Excellent correlation of base deficit to lactate and pH

                                bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                bull Assessing shock and efficacy of resuscitation

                                bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                Resuscitation End Points

                                bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                ndash Mentation

                                ndash UO

                                ndash Labs base deficit serum lactate serum pH

                                Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                urine output remain standard of carebull Uncompensated shock requires additional

                                resuscitationbull However after normalizing the above up to 85 of

                                severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                bull Better markers of adequate resuscitation are needed

                                Goal Directed Therapy PEARLbull Recognize trouble

                                ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                ndash Anticoagulantsndash Beta blockers

                                bull Early invasive monitoringbull Follow resuscitation goals

                                Optimizing Prehospital Resuscitation

                                bull Low volume fluid administration in penetrating injuries

                                bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                sheetsbinderbull Tourniquetsbull Scoop and run transports

                                based on ldquogolden hourrdquo

                                ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                Optimizing ResuscitationOptimizing Resuscitation

                                Prehospital Topicals 2010 Hemostatic Field Dressing

                                bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                Tourniquets 2010

                                40

                                Indications for Tourniquetsbull Stop bleeding when life-

                                threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                bull Stop bleeding with traumatic amputation

                                Intraosseous Infusion Devices 2010

                                EZ-IO

                                FAST1

                                Blood Substitutes 2010

                                bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                bull Ready for prime time ndash not yet but soon - maybe

                                bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                ndash JAMA - April 28 2008

                                Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                bull Direct pressure to all external bleeding

                                bull Rapid suturing of all scalp and facial wounds

                                bull Rapid application of ThomasHare Traction splints for femur fx

                                bull Binder for pelvic fxbull Rapid reduction and pressure

                                dressings of mangled extremities

                                Pelvic Binders 2010

                                Optimizing ED Trauma Resuscitation (cont)

                                bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                bull Use FAST to rapidly detect intra-abdominal fluid

                                bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                floor during chest tube insertion

                                Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                bull Intervene early in resuscitation to STOP bleeding

                                bull Conserve blood earlybull Aggressive rapid and efficient operative

                                interventionsbull Use novel methods to STOP bleeding in the

                                operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                coagulopathy

                                bull Controversialndash Whether to administer type and how much

                                bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                MTP Process Shands at UF

                                Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                amp notifies designated RN

                                Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                runner to BB with cross amp match

                                MTP runner delivers blood products to designated RN

                                Ismore MTPneeded

                                EDOR ICU

                                Designated RN assures bloodadministered per MD order

                                Designated RN assures blood administered per MD order

                                Designated RN sends MTP runner for more blood

                                MTP site

                                Ispt to be

                                transported withblood

                                Designated RN transportsblood with pt to location(ORICU)

                                END

                                END

                                END

                                YES NO

                                YES

                                NO

                                ED = Nurse ScribeOR = Circ RN notifies

                                Charge Nurse

                                62406

                                ED Thoracotomy for Moribund Patients

                                bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                bull Aortic cross-clamping

                                Optimizing Resuscitation Across the Continuum

                                bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                bullbull RegroupRegroup

                                Damage Control Focus on Physiology

                                bull Major paradigm shift in operative management of devastating injuries

                                bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                Damage Control Patient Selectionbull Instability

                                bull Hypothermia (lt 34deg C)

                                bull Coagulopathy

                                bull Acidosis (pHlt 72BD -8)

                                bull Major traumaAvoid ldquoground zero of damage control

                                (physiological decompensation)

                                Neurological All unconscious trauma patients have brain injury until proven otherwise

                                bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                bull Avoid hypotension in brain injured patients= poor outcome

                                bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                bull Urgent CT and expert neurosurgical care is a must

                                Questions

                                Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                Summary and Conclusionsbull It is truly all about the

                                patient

                                bull Team effort and framework is needed by design

                                bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                bull Trauma centers save lives

                                • Welcome to Trauma Tracks
                                • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                • OBJECTIVES
                                • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                • Current Outcomes for CY 2009
                                • FRAMEWORK
                                • ProfileCredentials of a Trauma Patient
                                • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                • Slide Number 10
                                • Slide Number 11
                                • Slide Number 12
                                • Slide Number 13
                                • Situation Awareness
                                • Most Potentially Preventable Trauma Deaths are related to
                                • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                • Optimizing Resuscitation Across the Continuum
                                • Airway All trauma patients need oxygen until proven otherwise
                                • Airway All unstable trauma patients need a definitive airway
                                • Prehospital Intubation
                                • Prehospital Intubation
                                • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                • Bridge Devices 2010
                                • Breathing All trauma patients need oxygen until proven otherwise
                                • CT Scan for thoracic trauma
                                • Hemorrhage All trauma patients are bleeding until proven otherwise
                                • Hemorrhage PEARL
                                • Hemorrhage 5 Anatomic Areas of Origin
                                • Hemorrhage Importance of Lactate amp BD
                                • Persistent Acidosis Indicates
                                • Base Deficit Categories
                                • Uses of Base Deficit in Trauma Care
                                • Resuscitation End Points
                                • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                • Goal Directed Therapy PEARL
                                • Optimizing Prehospital Resuscitation
                                • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                • PrehospitalTopicals 2010Hemostatic Field Dressing
                                • Tourniquets 2010
                                • Indications for Tourniquets
                                • Intraosseous Infusion Devices 2010
                                • Blood Substitutes 2010
                                • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                • Pelvic Binders 2010
                                • Optimizing ED Trauma Resuscitation (cont)
                                • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                • Slide Number 47
                                • Slide Number 48
                                • ED Thoracotomy for Moribund Patients
                                • Optimizing Resuscitation Across the Continuum
                                • Damage ControlFocus on Physiology
                                • Damage Control Patient Selection
                                • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                • Questions
                                • Summary and Conclusions

                                  Airway All trauma patients need oxygen until proven otherwise

                                  bull Airway patency and spontaneous breathing is the crucial first step and the single greatest priority in any injured patient

                                  bull Must be a skilled and have a backup plan if failure to intubate ie surgical airway

                                  bull Be aware of controversies in pre-hospital airway control and be familiar with different types of bridge devices

                                  Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                                  unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                                  of breathingmaximizes O2 delivery

                                  ndash Corrects acid base disturbances

                                  ndash Allow clinician to focus on other life-threatening issues

                                  Prehospital Intubation

                                  bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                                  bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                                  Prehospital Intubation

                                  bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                                  bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                                  bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                                  The impact of prehospital ventilation on outcome after severe traumatic brain injury

                                  Cusheri et al JTrauma 2007 Jun62(6)1330-6

                                  BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                                  determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                                  impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                                  with lower mortality after severe TBI

                                  Bridge Devices 2010

                                  LMAKing Airway

                                  Combitube

                                  Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                                  25 of all trauma deathsbull Understand the significance of

                                  patternsndash 1st and 2nd rib fxs abdominal breathing

                                  bull Treat the pneumo before ETTbull Life-threatening thoracic

                                  injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                                  1

                                  2

                                  CT Scan for thoracic trauma

                                  An occult pneumothorax seen on a CT scan that was not detected on a plain

                                  anteroposterior supine chest radiograph

                                  bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                                  bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                                  Hemorrhage All trauma patients are bleeding until proven otherwise

                                  bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                                  bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                                  bull Prevent shock by arresting the bleeding

                                  bull Mandates the earliest possible ldquogoal directed therapyrdquo

                                  Hemorrhage PEARLbull Recognize trouble

                                  ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                  increases morbidity and doubles mortality especially in head injured patients

                                  bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                  ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                  Hemorrhage 5 Anatomic Areas of Origin

                                  Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                  Hemorrhage Importance of Lactate amp BD

                                  bull For Resuscitation to Occurndash Adequate perfusion and

                                  ndash Tissue oxygenation must be restored

                                  bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                  ndash Controlling the bleeding

                                  Persistent Acidosis Indicates

                                  bull Continued bleeding

                                  bull Inadequate resuscitation

                                  bull Myocardial dysfunction

                                  dArr

                                  serum pH (735 ndash 745)uArr

                                  base deficit (2 to -2)uArr

                                  serum lactate (04 ndash 18)

                                  Base Deficit Categories

                                  bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                  A base deficit of -6 is a marker of severeinjury amp significant mortality

                                  Uses of Base Deficit in Trauma Care

                                  bull Excellent correlation of base deficit to lactate and pH

                                  bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                  bull Assessing shock and efficacy of resuscitation

                                  bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                  Resuscitation End Points

                                  bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                  ndash Mentation

                                  ndash UO

                                  ndash Labs base deficit serum lactate serum pH

                                  Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                  urine output remain standard of carebull Uncompensated shock requires additional

                                  resuscitationbull However after normalizing the above up to 85 of

                                  severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                  bull Better markers of adequate resuscitation are needed

                                  Goal Directed Therapy PEARLbull Recognize trouble

                                  ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                  ndash Anticoagulantsndash Beta blockers

                                  bull Early invasive monitoringbull Follow resuscitation goals

                                  Optimizing Prehospital Resuscitation

                                  bull Low volume fluid administration in penetrating injuries

                                  bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                  sheetsbinderbull Tourniquetsbull Scoop and run transports

                                  based on ldquogolden hourrdquo

                                  ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                  bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                  bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                  Optimizing ResuscitationOptimizing Resuscitation

                                  Prehospital Topicals 2010 Hemostatic Field Dressing

                                  bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                  bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                  Tourniquets 2010

                                  40

                                  Indications for Tourniquetsbull Stop bleeding when life-

                                  threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                  bull Stop bleeding with traumatic amputation

                                  Intraosseous Infusion Devices 2010

                                  EZ-IO

                                  FAST1

                                  Blood Substitutes 2010

                                  bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                  bull Ready for prime time ndash not yet but soon - maybe

                                  bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                  ndash JAMA - April 28 2008

                                  Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                  bull Direct pressure to all external bleeding

                                  bull Rapid suturing of all scalp and facial wounds

                                  bull Rapid application of ThomasHare Traction splints for femur fx

                                  bull Binder for pelvic fxbull Rapid reduction and pressure

                                  dressings of mangled extremities

                                  Pelvic Binders 2010

                                  Optimizing ED Trauma Resuscitation (cont)

                                  bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                  Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                  bull Use FAST to rapidly detect intra-abdominal fluid

                                  bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                  floor during chest tube insertion

                                  Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                  bull Intervene early in resuscitation to STOP bleeding

                                  bull Conserve blood earlybull Aggressive rapid and efficient operative

                                  interventionsbull Use novel methods to STOP bleeding in the

                                  operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                  coagulopathy

                                  bull Controversialndash Whether to administer type and how much

                                  bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                  Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                  MTP Process Shands at UF

                                  Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                  amp notifies designated RN

                                  Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                  refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                  Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                  runner to BB with cross amp match

                                  MTP runner delivers blood products to designated RN

                                  Ismore MTPneeded

                                  EDOR ICU

                                  Designated RN assures bloodadministered per MD order

                                  Designated RN assures blood administered per MD order

                                  Designated RN sends MTP runner for more blood

                                  MTP site

                                  Ispt to be

                                  transported withblood

                                  Designated RN transportsblood with pt to location(ORICU)

                                  END

                                  END

                                  END

                                  YES NO

                                  YES

                                  NO

                                  ED = Nurse ScribeOR = Circ RN notifies

                                  Charge Nurse

                                  62406

                                  ED Thoracotomy for Moribund Patients

                                  bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                  bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                  bull Aortic cross-clamping

                                  Optimizing Resuscitation Across the Continuum

                                  bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                  triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                  bullbull RegroupRegroup

                                  Damage Control Focus on Physiology

                                  bull Major paradigm shift in operative management of devastating injuries

                                  bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                  temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                  ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                  Damage Control Patient Selectionbull Instability

                                  bull Hypothermia (lt 34deg C)

                                  bull Coagulopathy

                                  bull Acidosis (pHlt 72BD -8)

                                  bull Major traumaAvoid ldquoground zero of damage control

                                  (physiological decompensation)

                                  Neurological All unconscious trauma patients have brain injury until proven otherwise

                                  bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                  bull Avoid hypotension in brain injured patients= poor outcome

                                  bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                  bull Urgent CT and expert neurosurgical care is a must

                                  Questions

                                  Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                  Summary and Conclusionsbull It is truly all about the

                                  patient

                                  bull Team effort and framework is needed by design

                                  bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                  bull Trauma centers save lives

                                  • Welcome to Trauma Tracks
                                  • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                  • OBJECTIVES
                                  • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                  • Current Outcomes for CY 2009
                                  • FRAMEWORK
                                  • ProfileCredentials of a Trauma Patient
                                  • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                  • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                  • Slide Number 10
                                  • Slide Number 11
                                  • Slide Number 12
                                  • Slide Number 13
                                  • Situation Awareness
                                  • Most Potentially Preventable Trauma Deaths are related to
                                  • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                  • Optimizing Resuscitation Across the Continuum
                                  • Airway All trauma patients need oxygen until proven otherwise
                                  • Airway All unstable trauma patients need a definitive airway
                                  • Prehospital Intubation
                                  • Prehospital Intubation
                                  • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                  • Bridge Devices 2010
                                  • Breathing All trauma patients need oxygen until proven otherwise
                                  • CT Scan for thoracic trauma
                                  • Hemorrhage All trauma patients are bleeding until proven otherwise
                                  • Hemorrhage PEARL
                                  • Hemorrhage 5 Anatomic Areas of Origin
                                  • Hemorrhage Importance of Lactate amp BD
                                  • Persistent Acidosis Indicates
                                  • Base Deficit Categories
                                  • Uses of Base Deficit in Trauma Care
                                  • Resuscitation End Points
                                  • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                  • Goal Directed Therapy PEARL
                                  • Optimizing Prehospital Resuscitation
                                  • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                  • PrehospitalTopicals 2010Hemostatic Field Dressing
                                  • Tourniquets 2010
                                  • Indications for Tourniquets
                                  • Intraosseous Infusion Devices 2010
                                  • Blood Substitutes 2010
                                  • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                  • Pelvic Binders 2010
                                  • Optimizing ED Trauma Resuscitation (cont)
                                  • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                  • Slide Number 47
                                  • Slide Number 48
                                  • ED Thoracotomy for Moribund Patients
                                  • Optimizing Resuscitation Across the Continuum
                                  • Damage ControlFocus on Physiology
                                  • Damage Control Patient Selection
                                  • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                  • Questions
                                  • Summary and Conclusions

                                    Airway All unstable trauma patients need a definitive airwaybull Hemodynamically

                                    unstable trauma patients need an early definitive airwayndash Prevents aspirationndash Reduces the oxygen debt

                                    of breathingmaximizes O2 delivery

                                    ndash Corrects acid base disturbances

                                    ndash Allow clinician to focus on other life-threatening issues

                                    Prehospital Intubation

                                    bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                                    bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                                    Prehospital Intubation

                                    bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                                    bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                                    bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                                    The impact of prehospital ventilation on outcome after severe traumatic brain injury

                                    Cusheri et al JTrauma 2007 Jun62(6)1330-6

                                    BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                                    determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                                    impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                                    with lower mortality after severe TBI

                                    Bridge Devices 2010

                                    LMAKing Airway

                                    Combitube

                                    Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                                    25 of all trauma deathsbull Understand the significance of

                                    patternsndash 1st and 2nd rib fxs abdominal breathing

                                    bull Treat the pneumo before ETTbull Life-threatening thoracic

                                    injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                                    1

                                    2

                                    CT Scan for thoracic trauma

                                    An occult pneumothorax seen on a CT scan that was not detected on a plain

                                    anteroposterior supine chest radiograph

                                    bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                                    bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                                    Hemorrhage All trauma patients are bleeding until proven otherwise

                                    bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                                    bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                                    bull Prevent shock by arresting the bleeding

                                    bull Mandates the earliest possible ldquogoal directed therapyrdquo

                                    Hemorrhage PEARLbull Recognize trouble

                                    ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                    increases morbidity and doubles mortality especially in head injured patients

                                    bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                    ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                    Hemorrhage 5 Anatomic Areas of Origin

                                    Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                    Hemorrhage Importance of Lactate amp BD

                                    bull For Resuscitation to Occurndash Adequate perfusion and

                                    ndash Tissue oxygenation must be restored

                                    bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                    ndash Controlling the bleeding

                                    Persistent Acidosis Indicates

                                    bull Continued bleeding

                                    bull Inadequate resuscitation

                                    bull Myocardial dysfunction

                                    dArr

                                    serum pH (735 ndash 745)uArr

                                    base deficit (2 to -2)uArr

                                    serum lactate (04 ndash 18)

                                    Base Deficit Categories

                                    bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                    A base deficit of -6 is a marker of severeinjury amp significant mortality

                                    Uses of Base Deficit in Trauma Care

                                    bull Excellent correlation of base deficit to lactate and pH

                                    bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                    bull Assessing shock and efficacy of resuscitation

                                    bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                    Resuscitation End Points

                                    bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                    ndash Mentation

                                    ndash UO

                                    ndash Labs base deficit serum lactate serum pH

                                    Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                    urine output remain standard of carebull Uncompensated shock requires additional

                                    resuscitationbull However after normalizing the above up to 85 of

                                    severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                    bull Better markers of adequate resuscitation are needed

                                    Goal Directed Therapy PEARLbull Recognize trouble

                                    ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                    ndash Anticoagulantsndash Beta blockers

                                    bull Early invasive monitoringbull Follow resuscitation goals

                                    Optimizing Prehospital Resuscitation

                                    bull Low volume fluid administration in penetrating injuries

                                    bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                    sheetsbinderbull Tourniquetsbull Scoop and run transports

                                    based on ldquogolden hourrdquo

                                    ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                    bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                    bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                    Optimizing ResuscitationOptimizing Resuscitation

                                    Prehospital Topicals 2010 Hemostatic Field Dressing

                                    bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                    bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                    Tourniquets 2010

                                    40

                                    Indications for Tourniquetsbull Stop bleeding when life-

                                    threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                    bull Stop bleeding with traumatic amputation

                                    Intraosseous Infusion Devices 2010

                                    EZ-IO

                                    FAST1

                                    Blood Substitutes 2010

                                    bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                    bull Ready for prime time ndash not yet but soon - maybe

                                    bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                    ndash JAMA - April 28 2008

                                    Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                    bull Direct pressure to all external bleeding

                                    bull Rapid suturing of all scalp and facial wounds

                                    bull Rapid application of ThomasHare Traction splints for femur fx

                                    bull Binder for pelvic fxbull Rapid reduction and pressure

                                    dressings of mangled extremities

                                    Pelvic Binders 2010

                                    Optimizing ED Trauma Resuscitation (cont)

                                    bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                    Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                    bull Use FAST to rapidly detect intra-abdominal fluid

                                    bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                    floor during chest tube insertion

                                    Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                    bull Intervene early in resuscitation to STOP bleeding

                                    bull Conserve blood earlybull Aggressive rapid and efficient operative

                                    interventionsbull Use novel methods to STOP bleeding in the

                                    operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                    coagulopathy

                                    bull Controversialndash Whether to administer type and how much

                                    bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                    Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                    MTP Process Shands at UF

                                    Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                    amp notifies designated RN

                                    Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                    refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                    Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                    runner to BB with cross amp match

                                    MTP runner delivers blood products to designated RN

                                    Ismore MTPneeded

                                    EDOR ICU

                                    Designated RN assures bloodadministered per MD order

                                    Designated RN assures blood administered per MD order

                                    Designated RN sends MTP runner for more blood

                                    MTP site

                                    Ispt to be

                                    transported withblood

                                    Designated RN transportsblood with pt to location(ORICU)

                                    END

                                    END

                                    END

                                    YES NO

                                    YES

                                    NO

                                    ED = Nurse ScribeOR = Circ RN notifies

                                    Charge Nurse

                                    62406

                                    ED Thoracotomy for Moribund Patients

                                    bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                    bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                    bull Aortic cross-clamping

                                    Optimizing Resuscitation Across the Continuum

                                    bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                    triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                    bullbull RegroupRegroup

                                    Damage Control Focus on Physiology

                                    bull Major paradigm shift in operative management of devastating injuries

                                    bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                    temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                    ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                    Damage Control Patient Selectionbull Instability

                                    bull Hypothermia (lt 34deg C)

                                    bull Coagulopathy

                                    bull Acidosis (pHlt 72BD -8)

                                    bull Major traumaAvoid ldquoground zero of damage control

                                    (physiological decompensation)

                                    Neurological All unconscious trauma patients have brain injury until proven otherwise

                                    bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                    bull Avoid hypotension in brain injured patients= poor outcome

                                    bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                    bull Urgent CT and expert neurosurgical care is a must

                                    Questions

                                    Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                    Summary and Conclusionsbull It is truly all about the

                                    patient

                                    bull Team effort and framework is needed by design

                                    bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                    bull Trauma centers save lives

                                    • Welcome to Trauma Tracks
                                    • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                    • OBJECTIVES
                                    • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                    • Current Outcomes for CY 2009
                                    • FRAMEWORK
                                    • ProfileCredentials of a Trauma Patient
                                    • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                    • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                    • Slide Number 10
                                    • Slide Number 11
                                    • Slide Number 12
                                    • Slide Number 13
                                    • Situation Awareness
                                    • Most Potentially Preventable Trauma Deaths are related to
                                    • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                    • Optimizing Resuscitation Across the Continuum
                                    • Airway All trauma patients need oxygen until proven otherwise
                                    • Airway All unstable trauma patients need a definitive airway
                                    • Prehospital Intubation
                                    • Prehospital Intubation
                                    • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                    • Bridge Devices 2010
                                    • Breathing All trauma patients need oxygen until proven otherwise
                                    • CT Scan for thoracic trauma
                                    • Hemorrhage All trauma patients are bleeding until proven otherwise
                                    • Hemorrhage PEARL
                                    • Hemorrhage 5 Anatomic Areas of Origin
                                    • Hemorrhage Importance of Lactate amp BD
                                    • Persistent Acidosis Indicates
                                    • Base Deficit Categories
                                    • Uses of Base Deficit in Trauma Care
                                    • Resuscitation End Points
                                    • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                    • Goal Directed Therapy PEARL
                                    • Optimizing Prehospital Resuscitation
                                    • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                    • PrehospitalTopicals 2010Hemostatic Field Dressing
                                    • Tourniquets 2010
                                    • Indications for Tourniquets
                                    • Intraosseous Infusion Devices 2010
                                    • Blood Substitutes 2010
                                    • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                    • Pelvic Binders 2010
                                    • Optimizing ED Trauma Resuscitation (cont)
                                    • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                    • Slide Number 47
                                    • Slide Number 48
                                    • ED Thoracotomy for Moribund Patients
                                    • Optimizing Resuscitation Across the Continuum
                                    • Damage ControlFocus on Physiology
                                    • Damage Control Patient Selection
                                    • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                    • Questions
                                    • Summary and Conclusions

                                      Prehospital Intubation

                                      bull Improves outcome(Winchell amp Hoyt 1997)Field intubation was associated with significant decreases Field intubation was associated with significant decreases in mortality from 36 to 26 in the full study groupin mortality from 36 to 26 in the full study groupfrom 57 to 36 in patients with severe head injury from 57 to 36 in patients with severe head injury from 50 to 23 in patients with isolated severe head injurfrom 50 to 23 in patients with isolated severe head injuryy

                                      bullbull Worsens outcomeWorsens outcome(Murray 2000)(Bocchichio 2003)(Cooper 2001)Pediatric patients

                                      Prehospital Intubation

                                      bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                                      bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                                      bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                                      The impact of prehospital ventilation on outcome after severe traumatic brain injury

                                      Cusheri et al JTrauma 2007 Jun62(6)1330-6

                                      BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                                      determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                                      impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                                      with lower mortality after severe TBI

                                      Bridge Devices 2010

                                      LMAKing Airway

                                      Combitube

                                      Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                                      25 of all trauma deathsbull Understand the significance of

                                      patternsndash 1st and 2nd rib fxs abdominal breathing

                                      bull Treat the pneumo before ETTbull Life-threatening thoracic

                                      injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                                      1

                                      2

                                      CT Scan for thoracic trauma

                                      An occult pneumothorax seen on a CT scan that was not detected on a plain

                                      anteroposterior supine chest radiograph

                                      bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                                      bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                                      Hemorrhage All trauma patients are bleeding until proven otherwise

                                      bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                                      bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                                      bull Prevent shock by arresting the bleeding

                                      bull Mandates the earliest possible ldquogoal directed therapyrdquo

                                      Hemorrhage PEARLbull Recognize trouble

                                      ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                      increases morbidity and doubles mortality especially in head injured patients

                                      bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                      ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                      Hemorrhage 5 Anatomic Areas of Origin

                                      Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                      Hemorrhage Importance of Lactate amp BD

                                      bull For Resuscitation to Occurndash Adequate perfusion and

                                      ndash Tissue oxygenation must be restored

                                      bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                      ndash Controlling the bleeding

                                      Persistent Acidosis Indicates

                                      bull Continued bleeding

                                      bull Inadequate resuscitation

                                      bull Myocardial dysfunction

                                      dArr

                                      serum pH (735 ndash 745)uArr

                                      base deficit (2 to -2)uArr

                                      serum lactate (04 ndash 18)

                                      Base Deficit Categories

                                      bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                      A base deficit of -6 is a marker of severeinjury amp significant mortality

                                      Uses of Base Deficit in Trauma Care

                                      bull Excellent correlation of base deficit to lactate and pH

                                      bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                      bull Assessing shock and efficacy of resuscitation

                                      bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                      Resuscitation End Points

                                      bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                      ndash Mentation

                                      ndash UO

                                      ndash Labs base deficit serum lactate serum pH

                                      Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                      urine output remain standard of carebull Uncompensated shock requires additional

                                      resuscitationbull However after normalizing the above up to 85 of

                                      severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                      bull Better markers of adequate resuscitation are needed

                                      Goal Directed Therapy PEARLbull Recognize trouble

                                      ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                      ndash Anticoagulantsndash Beta blockers

                                      bull Early invasive monitoringbull Follow resuscitation goals

                                      Optimizing Prehospital Resuscitation

                                      bull Low volume fluid administration in penetrating injuries

                                      bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                      sheetsbinderbull Tourniquetsbull Scoop and run transports

                                      based on ldquogolden hourrdquo

                                      ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                      bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                      bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                      Optimizing ResuscitationOptimizing Resuscitation

                                      Prehospital Topicals 2010 Hemostatic Field Dressing

                                      bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                      bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                      Tourniquets 2010

                                      40

                                      Indications for Tourniquetsbull Stop bleeding when life-

                                      threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                      bull Stop bleeding with traumatic amputation

                                      Intraosseous Infusion Devices 2010

                                      EZ-IO

                                      FAST1

                                      Blood Substitutes 2010

                                      bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                      bull Ready for prime time ndash not yet but soon - maybe

                                      bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                      ndash JAMA - April 28 2008

                                      Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                      bull Direct pressure to all external bleeding

                                      bull Rapid suturing of all scalp and facial wounds

                                      bull Rapid application of ThomasHare Traction splints for femur fx

                                      bull Binder for pelvic fxbull Rapid reduction and pressure

                                      dressings of mangled extremities

                                      Pelvic Binders 2010

                                      Optimizing ED Trauma Resuscitation (cont)

                                      bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                      Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                      bull Use FAST to rapidly detect intra-abdominal fluid

                                      bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                      floor during chest tube insertion

                                      Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                      bull Intervene early in resuscitation to STOP bleeding

                                      bull Conserve blood earlybull Aggressive rapid and efficient operative

                                      interventionsbull Use novel methods to STOP bleeding in the

                                      operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                      coagulopathy

                                      bull Controversialndash Whether to administer type and how much

                                      bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                      Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                      MTP Process Shands at UF

                                      Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                      amp notifies designated RN

                                      Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                      refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                      Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                      runner to BB with cross amp match

                                      MTP runner delivers blood products to designated RN

                                      Ismore MTPneeded

                                      EDOR ICU

                                      Designated RN assures bloodadministered per MD order

                                      Designated RN assures blood administered per MD order

                                      Designated RN sends MTP runner for more blood

                                      MTP site

                                      Ispt to be

                                      transported withblood

                                      Designated RN transportsblood with pt to location(ORICU)

                                      END

                                      END

                                      END

                                      YES NO

                                      YES

                                      NO

                                      ED = Nurse ScribeOR = Circ RN notifies

                                      Charge Nurse

                                      62406

                                      ED Thoracotomy for Moribund Patients

                                      bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                      bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                      bull Aortic cross-clamping

                                      Optimizing Resuscitation Across the Continuum

                                      bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                      triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                      bullbull RegroupRegroup

                                      Damage Control Focus on Physiology

                                      bull Major paradigm shift in operative management of devastating injuries

                                      bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                      temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                      ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                      Damage Control Patient Selectionbull Instability

                                      bull Hypothermia (lt 34deg C)

                                      bull Coagulopathy

                                      bull Acidosis (pHlt 72BD -8)

                                      bull Major traumaAvoid ldquoground zero of damage control

                                      (physiological decompensation)

                                      Neurological All unconscious trauma patients have brain injury until proven otherwise

                                      bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                      bull Avoid hypotension in brain injured patients= poor outcome

                                      bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                      bull Urgent CT and expert neurosurgical care is a must

                                      Questions

                                      Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                      Summary and Conclusionsbull It is truly all about the

                                      patient

                                      bull Team effort and framework is needed by design

                                      bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                      bull Trauma centers save lives

                                      • Welcome to Trauma Tracks
                                      • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                      • OBJECTIVES
                                      • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                      • Current Outcomes for CY 2009
                                      • FRAMEWORK
                                      • ProfileCredentials of a Trauma Patient
                                      • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                      • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                      • Slide Number 10
                                      • Slide Number 11
                                      • Slide Number 12
                                      • Slide Number 13
                                      • Situation Awareness
                                      • Most Potentially Preventable Trauma Deaths are related to
                                      • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                      • Optimizing Resuscitation Across the Continuum
                                      • Airway All trauma patients need oxygen until proven otherwise
                                      • Airway All unstable trauma patients need a definitive airway
                                      • Prehospital Intubation
                                      • Prehospital Intubation
                                      • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                      • Bridge Devices 2010
                                      • Breathing All trauma patients need oxygen until proven otherwise
                                      • CT Scan for thoracic trauma
                                      • Hemorrhage All trauma patients are bleeding until proven otherwise
                                      • Hemorrhage PEARL
                                      • Hemorrhage 5 Anatomic Areas of Origin
                                      • Hemorrhage Importance of Lactate amp BD
                                      • Persistent Acidosis Indicates
                                      • Base Deficit Categories
                                      • Uses of Base Deficit in Trauma Care
                                      • Resuscitation End Points
                                      • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                      • Goal Directed Therapy PEARL
                                      • Optimizing Prehospital Resuscitation
                                      • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                      • PrehospitalTopicals 2010Hemostatic Field Dressing
                                      • Tourniquets 2010
                                      • Indications for Tourniquets
                                      • Intraosseous Infusion Devices 2010
                                      • Blood Substitutes 2010
                                      • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                      • Pelvic Binders 2010
                                      • Optimizing ED Trauma Resuscitation (cont)
                                      • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                      • Slide Number 47
                                      • Slide Number 48
                                      • ED Thoracotomy for Moribund Patients
                                      • Optimizing Resuscitation Across the Continuum
                                      • Damage ControlFocus on Physiology
                                      • Damage Control Patient Selection
                                      • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                      • Questions
                                      • Summary and Conclusions

                                        Prehospital Intubation

                                        bullbull Does not change outcome in head injured patientsDoes not change outcome in head injured patients (Arbabi et al 2004)(Arbabi et al 2004)

                                        bullbull Similar or greater mortality than BVMSimilar or greater mortality than BVM (Stockinger and (Stockinger and McSwain 2004McSwain 2004))

                                        bullbull Greater mortality than controls 33 vs 24 with RSI in Greater mortality than controls 33 vs 24 with RSI in head injuryhead injury (Davis Hoyt et al 2003)(Davis Hoyt et al 2003)

                                        The impact of prehospital ventilation on outcome after severe traumatic brain injury

                                        Cusheri et al JTrauma 2007 Jun62(6)1330-6

                                        BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                                        determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                                        impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                                        with lower mortality after severe TBI

                                        Bridge Devices 2010

                                        LMAKing Airway

                                        Combitube

                                        Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                                        25 of all trauma deathsbull Understand the significance of

                                        patternsndash 1st and 2nd rib fxs abdominal breathing

                                        bull Treat the pneumo before ETTbull Life-threatening thoracic

                                        injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                                        1

                                        2

                                        CT Scan for thoracic trauma

                                        An occult pneumothorax seen on a CT scan that was not detected on a plain

                                        anteroposterior supine chest radiograph

                                        bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                                        bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                                        Hemorrhage All trauma patients are bleeding until proven otherwise

                                        bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                                        bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                                        bull Prevent shock by arresting the bleeding

                                        bull Mandates the earliest possible ldquogoal directed therapyrdquo

                                        Hemorrhage PEARLbull Recognize trouble

                                        ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                        increases morbidity and doubles mortality especially in head injured patients

                                        bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                        ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                        Hemorrhage 5 Anatomic Areas of Origin

                                        Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                        Hemorrhage Importance of Lactate amp BD

                                        bull For Resuscitation to Occurndash Adequate perfusion and

                                        ndash Tissue oxygenation must be restored

                                        bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                        ndash Controlling the bleeding

                                        Persistent Acidosis Indicates

                                        bull Continued bleeding

                                        bull Inadequate resuscitation

                                        bull Myocardial dysfunction

                                        dArr

                                        serum pH (735 ndash 745)uArr

                                        base deficit (2 to -2)uArr

                                        serum lactate (04 ndash 18)

                                        Base Deficit Categories

                                        bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                        A base deficit of -6 is a marker of severeinjury amp significant mortality

                                        Uses of Base Deficit in Trauma Care

                                        bull Excellent correlation of base deficit to lactate and pH

                                        bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                        bull Assessing shock and efficacy of resuscitation

                                        bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                        Resuscitation End Points

                                        bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                        ndash Mentation

                                        ndash UO

                                        ndash Labs base deficit serum lactate serum pH

                                        Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                        urine output remain standard of carebull Uncompensated shock requires additional

                                        resuscitationbull However after normalizing the above up to 85 of

                                        severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                        bull Better markers of adequate resuscitation are needed

                                        Goal Directed Therapy PEARLbull Recognize trouble

                                        ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                        ndash Anticoagulantsndash Beta blockers

                                        bull Early invasive monitoringbull Follow resuscitation goals

                                        Optimizing Prehospital Resuscitation

                                        bull Low volume fluid administration in penetrating injuries

                                        bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                        sheetsbinderbull Tourniquetsbull Scoop and run transports

                                        based on ldquogolden hourrdquo

                                        ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                        bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                        bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                        Optimizing ResuscitationOptimizing Resuscitation

                                        Prehospital Topicals 2010 Hemostatic Field Dressing

                                        bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                        bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                        Tourniquets 2010

                                        40

                                        Indications for Tourniquetsbull Stop bleeding when life-

                                        threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                        bull Stop bleeding with traumatic amputation

                                        Intraosseous Infusion Devices 2010

                                        EZ-IO

                                        FAST1

                                        Blood Substitutes 2010

                                        bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                        bull Ready for prime time ndash not yet but soon - maybe

                                        bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                        ndash JAMA - April 28 2008

                                        Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                        bull Direct pressure to all external bleeding

                                        bull Rapid suturing of all scalp and facial wounds

                                        bull Rapid application of ThomasHare Traction splints for femur fx

                                        bull Binder for pelvic fxbull Rapid reduction and pressure

                                        dressings of mangled extremities

                                        Pelvic Binders 2010

                                        Optimizing ED Trauma Resuscitation (cont)

                                        bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                        Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                        bull Use FAST to rapidly detect intra-abdominal fluid

                                        bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                        floor during chest tube insertion

                                        Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                        bull Intervene early in resuscitation to STOP bleeding

                                        bull Conserve blood earlybull Aggressive rapid and efficient operative

                                        interventionsbull Use novel methods to STOP bleeding in the

                                        operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                        coagulopathy

                                        bull Controversialndash Whether to administer type and how much

                                        bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                        Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                        MTP Process Shands at UF

                                        Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                        amp notifies designated RN

                                        Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                        refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                        Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                        runner to BB with cross amp match

                                        MTP runner delivers blood products to designated RN

                                        Ismore MTPneeded

                                        EDOR ICU

                                        Designated RN assures bloodadministered per MD order

                                        Designated RN assures blood administered per MD order

                                        Designated RN sends MTP runner for more blood

                                        MTP site

                                        Ispt to be

                                        transported withblood

                                        Designated RN transportsblood with pt to location(ORICU)

                                        END

                                        END

                                        END

                                        YES NO

                                        YES

                                        NO

                                        ED = Nurse ScribeOR = Circ RN notifies

                                        Charge Nurse

                                        62406

                                        ED Thoracotomy for Moribund Patients

                                        bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                        bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                        bull Aortic cross-clamping

                                        Optimizing Resuscitation Across the Continuum

                                        bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                        triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                        bullbull RegroupRegroup

                                        Damage Control Focus on Physiology

                                        bull Major paradigm shift in operative management of devastating injuries

                                        bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                        temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                        ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                        Damage Control Patient Selectionbull Instability

                                        bull Hypothermia (lt 34deg C)

                                        bull Coagulopathy

                                        bull Acidosis (pHlt 72BD -8)

                                        bull Major traumaAvoid ldquoground zero of damage control

                                        (physiological decompensation)

                                        Neurological All unconscious trauma patients have brain injury until proven otherwise

                                        bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                        bull Avoid hypotension in brain injured patients= poor outcome

                                        bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                        bull Urgent CT and expert neurosurgical care is a must

                                        Questions

                                        Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                        Summary and Conclusionsbull It is truly all about the

                                        patient

                                        bull Team effort and framework is needed by design

                                        bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                        bull Trauma centers save lives

                                        • Welcome to Trauma Tracks
                                        • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                        • OBJECTIVES
                                        • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                        • Current Outcomes for CY 2009
                                        • FRAMEWORK
                                        • ProfileCredentials of a Trauma Patient
                                        • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                        • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                        • Slide Number 10
                                        • Slide Number 11
                                        • Slide Number 12
                                        • Slide Number 13
                                        • Situation Awareness
                                        • Most Potentially Preventable Trauma Deaths are related to
                                        • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                        • Optimizing Resuscitation Across the Continuum
                                        • Airway All trauma patients need oxygen until proven otherwise
                                        • Airway All unstable trauma patients need a definitive airway
                                        • Prehospital Intubation
                                        • Prehospital Intubation
                                        • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                        • Bridge Devices 2010
                                        • Breathing All trauma patients need oxygen until proven otherwise
                                        • CT Scan for thoracic trauma
                                        • Hemorrhage All trauma patients are bleeding until proven otherwise
                                        • Hemorrhage PEARL
                                        • Hemorrhage 5 Anatomic Areas of Origin
                                        • Hemorrhage Importance of Lactate amp BD
                                        • Persistent Acidosis Indicates
                                        • Base Deficit Categories
                                        • Uses of Base Deficit in Trauma Care
                                        • Resuscitation End Points
                                        • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                        • Goal Directed Therapy PEARL
                                        • Optimizing Prehospital Resuscitation
                                        • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                        • PrehospitalTopicals 2010Hemostatic Field Dressing
                                        • Tourniquets 2010
                                        • Indications for Tourniquets
                                        • Intraosseous Infusion Devices 2010
                                        • Blood Substitutes 2010
                                        • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                        • Pelvic Binders 2010
                                        • Optimizing ED Trauma Resuscitation (cont)
                                        • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                        • Slide Number 47
                                        • Slide Number 48
                                        • ED Thoracotomy for Moribund Patients
                                        • Optimizing Resuscitation Across the Continuum
                                        • Damage ControlFocus on Physiology
                                        • Damage Control Patient Selection
                                        • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                        • Questions
                                        • Summary and Conclusions

                                          The impact of prehospital ventilation on outcome after severe traumatic brain injury

                                          Cusheri et al JTrauma 2007 Jun62(6)1330-6

                                          BACKGROUND Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation which is detrimental after traumatic brain injury (TBI) and impairs venous return in patients with hypovolemia We sought to

                                          determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the

                                          impact of ventilation on outcome after severe TBI CONCLUSION Targeted prehospital ventilation is associated

                                          with lower mortality after severe TBI

                                          Bridge Devices 2010

                                          LMAKing Airway

                                          Combitube

                                          Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                                          25 of all trauma deathsbull Understand the significance of

                                          patternsndash 1st and 2nd rib fxs abdominal breathing

                                          bull Treat the pneumo before ETTbull Life-threatening thoracic

                                          injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                                          1

                                          2

                                          CT Scan for thoracic trauma

                                          An occult pneumothorax seen on a CT scan that was not detected on a plain

                                          anteroposterior supine chest radiograph

                                          bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                                          bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                                          Hemorrhage All trauma patients are bleeding until proven otherwise

                                          bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                                          bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                                          bull Prevent shock by arresting the bleeding

                                          bull Mandates the earliest possible ldquogoal directed therapyrdquo

                                          Hemorrhage PEARLbull Recognize trouble

                                          ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                          increases morbidity and doubles mortality especially in head injured patients

                                          bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                          ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                          Hemorrhage 5 Anatomic Areas of Origin

                                          Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                          Hemorrhage Importance of Lactate amp BD

                                          bull For Resuscitation to Occurndash Adequate perfusion and

                                          ndash Tissue oxygenation must be restored

                                          bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                          ndash Controlling the bleeding

                                          Persistent Acidosis Indicates

                                          bull Continued bleeding

                                          bull Inadequate resuscitation

                                          bull Myocardial dysfunction

                                          dArr

                                          serum pH (735 ndash 745)uArr

                                          base deficit (2 to -2)uArr

                                          serum lactate (04 ndash 18)

                                          Base Deficit Categories

                                          bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                          A base deficit of -6 is a marker of severeinjury amp significant mortality

                                          Uses of Base Deficit in Trauma Care

                                          bull Excellent correlation of base deficit to lactate and pH

                                          bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                          bull Assessing shock and efficacy of resuscitation

                                          bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                          Resuscitation End Points

                                          bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                          ndash Mentation

                                          ndash UO

                                          ndash Labs base deficit serum lactate serum pH

                                          Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                          urine output remain standard of carebull Uncompensated shock requires additional

                                          resuscitationbull However after normalizing the above up to 85 of

                                          severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                          bull Better markers of adequate resuscitation are needed

                                          Goal Directed Therapy PEARLbull Recognize trouble

                                          ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                          ndash Anticoagulantsndash Beta blockers

                                          bull Early invasive monitoringbull Follow resuscitation goals

                                          Optimizing Prehospital Resuscitation

                                          bull Low volume fluid administration in penetrating injuries

                                          bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                          sheetsbinderbull Tourniquetsbull Scoop and run transports

                                          based on ldquogolden hourrdquo

                                          ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                          bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                          bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                          Optimizing ResuscitationOptimizing Resuscitation

                                          Prehospital Topicals 2010 Hemostatic Field Dressing

                                          bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                          bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                          Tourniquets 2010

                                          40

                                          Indications for Tourniquetsbull Stop bleeding when life-

                                          threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                          bull Stop bleeding with traumatic amputation

                                          Intraosseous Infusion Devices 2010

                                          EZ-IO

                                          FAST1

                                          Blood Substitutes 2010

                                          bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                          bull Ready for prime time ndash not yet but soon - maybe

                                          bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                          ndash JAMA - April 28 2008

                                          Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                          bull Direct pressure to all external bleeding

                                          bull Rapid suturing of all scalp and facial wounds

                                          bull Rapid application of ThomasHare Traction splints for femur fx

                                          bull Binder for pelvic fxbull Rapid reduction and pressure

                                          dressings of mangled extremities

                                          Pelvic Binders 2010

                                          Optimizing ED Trauma Resuscitation (cont)

                                          bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                          Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                          bull Use FAST to rapidly detect intra-abdominal fluid

                                          bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                          floor during chest tube insertion

                                          Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                          bull Intervene early in resuscitation to STOP bleeding

                                          bull Conserve blood earlybull Aggressive rapid and efficient operative

                                          interventionsbull Use novel methods to STOP bleeding in the

                                          operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                          coagulopathy

                                          bull Controversialndash Whether to administer type and how much

                                          bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                          Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                          MTP Process Shands at UF

                                          Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                          amp notifies designated RN

                                          Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                          refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                          Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                          runner to BB with cross amp match

                                          MTP runner delivers blood products to designated RN

                                          Ismore MTPneeded

                                          EDOR ICU

                                          Designated RN assures bloodadministered per MD order

                                          Designated RN assures blood administered per MD order

                                          Designated RN sends MTP runner for more blood

                                          MTP site

                                          Ispt to be

                                          transported withblood

                                          Designated RN transportsblood with pt to location(ORICU)

                                          END

                                          END

                                          END

                                          YES NO

                                          YES

                                          NO

                                          ED = Nurse ScribeOR = Circ RN notifies

                                          Charge Nurse

                                          62406

                                          ED Thoracotomy for Moribund Patients

                                          bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                          bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                          bull Aortic cross-clamping

                                          Optimizing Resuscitation Across the Continuum

                                          bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                          triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                          bullbull RegroupRegroup

                                          Damage Control Focus on Physiology

                                          bull Major paradigm shift in operative management of devastating injuries

                                          bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                          temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                          ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                          Damage Control Patient Selectionbull Instability

                                          bull Hypothermia (lt 34deg C)

                                          bull Coagulopathy

                                          bull Acidosis (pHlt 72BD -8)

                                          bull Major traumaAvoid ldquoground zero of damage control

                                          (physiological decompensation)

                                          Neurological All unconscious trauma patients have brain injury until proven otherwise

                                          bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                          bull Avoid hypotension in brain injured patients= poor outcome

                                          bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                          bull Urgent CT and expert neurosurgical care is a must

                                          Questions

                                          Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                          Summary and Conclusionsbull It is truly all about the

                                          patient

                                          bull Team effort and framework is needed by design

                                          bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                          bull Trauma centers save lives

                                          • Welcome to Trauma Tracks
                                          • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                          • OBJECTIVES
                                          • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                          • Current Outcomes for CY 2009
                                          • FRAMEWORK
                                          • ProfileCredentials of a Trauma Patient
                                          • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                          • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                          • Slide Number 10
                                          • Slide Number 11
                                          • Slide Number 12
                                          • Slide Number 13
                                          • Situation Awareness
                                          • Most Potentially Preventable Trauma Deaths are related to
                                          • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                          • Optimizing Resuscitation Across the Continuum
                                          • Airway All trauma patients need oxygen until proven otherwise
                                          • Airway All unstable trauma patients need a definitive airway
                                          • Prehospital Intubation
                                          • Prehospital Intubation
                                          • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                          • Bridge Devices 2010
                                          • Breathing All trauma patients need oxygen until proven otherwise
                                          • CT Scan for thoracic trauma
                                          • Hemorrhage All trauma patients are bleeding until proven otherwise
                                          • Hemorrhage PEARL
                                          • Hemorrhage 5 Anatomic Areas of Origin
                                          • Hemorrhage Importance of Lactate amp BD
                                          • Persistent Acidosis Indicates
                                          • Base Deficit Categories
                                          • Uses of Base Deficit in Trauma Care
                                          • Resuscitation End Points
                                          • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                          • Goal Directed Therapy PEARL
                                          • Optimizing Prehospital Resuscitation
                                          • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                          • PrehospitalTopicals 2010Hemostatic Field Dressing
                                          • Tourniquets 2010
                                          • Indications for Tourniquets
                                          • Intraosseous Infusion Devices 2010
                                          • Blood Substitutes 2010
                                          • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                          • Pelvic Binders 2010
                                          • Optimizing ED Trauma Resuscitation (cont)
                                          • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                          • Slide Number 47
                                          • Slide Number 48
                                          • ED Thoracotomy for Moribund Patients
                                          • Optimizing Resuscitation Across the Continuum
                                          • Damage ControlFocus on Physiology
                                          • Damage Control Patient Selection
                                          • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                          • Questions
                                          • Summary and Conclusions

                                            Bridge Devices 2010

                                            LMAKing Airway

                                            Combitube

                                            Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                                            25 of all trauma deathsbull Understand the significance of

                                            patternsndash 1st and 2nd rib fxs abdominal breathing

                                            bull Treat the pneumo before ETTbull Life-threatening thoracic

                                            injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                                            1

                                            2

                                            CT Scan for thoracic trauma

                                            An occult pneumothorax seen on a CT scan that was not detected on a plain

                                            anteroposterior supine chest radiograph

                                            bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                                            bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                                            Hemorrhage All trauma patients are bleeding until proven otherwise

                                            bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                                            bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                                            bull Prevent shock by arresting the bleeding

                                            bull Mandates the earliest possible ldquogoal directed therapyrdquo

                                            Hemorrhage PEARLbull Recognize trouble

                                            ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                            increases morbidity and doubles mortality especially in head injured patients

                                            bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                            ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                            Hemorrhage 5 Anatomic Areas of Origin

                                            Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                            Hemorrhage Importance of Lactate amp BD

                                            bull For Resuscitation to Occurndash Adequate perfusion and

                                            ndash Tissue oxygenation must be restored

                                            bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                            ndash Controlling the bleeding

                                            Persistent Acidosis Indicates

                                            bull Continued bleeding

                                            bull Inadequate resuscitation

                                            bull Myocardial dysfunction

                                            dArr

                                            serum pH (735 ndash 745)uArr

                                            base deficit (2 to -2)uArr

                                            serum lactate (04 ndash 18)

                                            Base Deficit Categories

                                            bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                            A base deficit of -6 is a marker of severeinjury amp significant mortality

                                            Uses of Base Deficit in Trauma Care

                                            bull Excellent correlation of base deficit to lactate and pH

                                            bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                            bull Assessing shock and efficacy of resuscitation

                                            bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                            Resuscitation End Points

                                            bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                            ndash Mentation

                                            ndash UO

                                            ndash Labs base deficit serum lactate serum pH

                                            Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                            urine output remain standard of carebull Uncompensated shock requires additional

                                            resuscitationbull However after normalizing the above up to 85 of

                                            severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                            bull Better markers of adequate resuscitation are needed

                                            Goal Directed Therapy PEARLbull Recognize trouble

                                            ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                            ndash Anticoagulantsndash Beta blockers

                                            bull Early invasive monitoringbull Follow resuscitation goals

                                            Optimizing Prehospital Resuscitation

                                            bull Low volume fluid administration in penetrating injuries

                                            bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                            sheetsbinderbull Tourniquetsbull Scoop and run transports

                                            based on ldquogolden hourrdquo

                                            ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                            bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                            bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                            Optimizing ResuscitationOptimizing Resuscitation

                                            Prehospital Topicals 2010 Hemostatic Field Dressing

                                            bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                            bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                            Tourniquets 2010

                                            40

                                            Indications for Tourniquetsbull Stop bleeding when life-

                                            threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                            bull Stop bleeding with traumatic amputation

                                            Intraosseous Infusion Devices 2010

                                            EZ-IO

                                            FAST1

                                            Blood Substitutes 2010

                                            bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                            bull Ready for prime time ndash not yet but soon - maybe

                                            bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                            ndash JAMA - April 28 2008

                                            Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                            bull Direct pressure to all external bleeding

                                            bull Rapid suturing of all scalp and facial wounds

                                            bull Rapid application of ThomasHare Traction splints for femur fx

                                            bull Binder for pelvic fxbull Rapid reduction and pressure

                                            dressings of mangled extremities

                                            Pelvic Binders 2010

                                            Optimizing ED Trauma Resuscitation (cont)

                                            bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                            Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                            bull Use FAST to rapidly detect intra-abdominal fluid

                                            bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                            floor during chest tube insertion

                                            Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                            bull Intervene early in resuscitation to STOP bleeding

                                            bull Conserve blood earlybull Aggressive rapid and efficient operative

                                            interventionsbull Use novel methods to STOP bleeding in the

                                            operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                            coagulopathy

                                            bull Controversialndash Whether to administer type and how much

                                            bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                            Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                            MTP Process Shands at UF

                                            Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                            amp notifies designated RN

                                            Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                            refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                            Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                            runner to BB with cross amp match

                                            MTP runner delivers blood products to designated RN

                                            Ismore MTPneeded

                                            EDOR ICU

                                            Designated RN assures bloodadministered per MD order

                                            Designated RN assures blood administered per MD order

                                            Designated RN sends MTP runner for more blood

                                            MTP site

                                            Ispt to be

                                            transported withblood

                                            Designated RN transportsblood with pt to location(ORICU)

                                            END

                                            END

                                            END

                                            YES NO

                                            YES

                                            NO

                                            ED = Nurse ScribeOR = Circ RN notifies

                                            Charge Nurse

                                            62406

                                            ED Thoracotomy for Moribund Patients

                                            bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                            bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                            bull Aortic cross-clamping

                                            Optimizing Resuscitation Across the Continuum

                                            bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                            triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                            bullbull RegroupRegroup

                                            Damage Control Focus on Physiology

                                            bull Major paradigm shift in operative management of devastating injuries

                                            bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                            temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                            ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                            Damage Control Patient Selectionbull Instability

                                            bull Hypothermia (lt 34deg C)

                                            bull Coagulopathy

                                            bull Acidosis (pHlt 72BD -8)

                                            bull Major traumaAvoid ldquoground zero of damage control

                                            (physiological decompensation)

                                            Neurological All unconscious trauma patients have brain injury until proven otherwise

                                            bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                            bull Avoid hypotension in brain injured patients= poor outcome

                                            bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                            bull Urgent CT and expert neurosurgical care is a must

                                            Questions

                                            Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                            Summary and Conclusionsbull It is truly all about the

                                            patient

                                            bull Team effort and framework is needed by design

                                            bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                            bull Trauma centers save lives

                                            • Welcome to Trauma Tracks
                                            • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                            • OBJECTIVES
                                            • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                            • Current Outcomes for CY 2009
                                            • FRAMEWORK
                                            • ProfileCredentials of a Trauma Patient
                                            • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                            • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                            • Slide Number 10
                                            • Slide Number 11
                                            • Slide Number 12
                                            • Slide Number 13
                                            • Situation Awareness
                                            • Most Potentially Preventable Trauma Deaths are related to
                                            • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                            • Optimizing Resuscitation Across the Continuum
                                            • Airway All trauma patients need oxygen until proven otherwise
                                            • Airway All unstable trauma patients need a definitive airway
                                            • Prehospital Intubation
                                            • Prehospital Intubation
                                            • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                            • Bridge Devices 2010
                                            • Breathing All trauma patients need oxygen until proven otherwise
                                            • CT Scan for thoracic trauma
                                            • Hemorrhage All trauma patients are bleeding until proven otherwise
                                            • Hemorrhage PEARL
                                            • Hemorrhage 5 Anatomic Areas of Origin
                                            • Hemorrhage Importance of Lactate amp BD
                                            • Persistent Acidosis Indicates
                                            • Base Deficit Categories
                                            • Uses of Base Deficit in Trauma Care
                                            • Resuscitation End Points
                                            • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                            • Goal Directed Therapy PEARL
                                            • Optimizing Prehospital Resuscitation
                                            • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                            • PrehospitalTopicals 2010Hemostatic Field Dressing
                                            • Tourniquets 2010
                                            • Indications for Tourniquets
                                            • Intraosseous Infusion Devices 2010
                                            • Blood Substitutes 2010
                                            • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                            • Pelvic Binders 2010
                                            • Optimizing ED Trauma Resuscitation (cont)
                                            • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                            • Slide Number 47
                                            • Slide Number 48
                                            • ED Thoracotomy for Moribund Patients
                                            • Optimizing Resuscitation Across the Continuum
                                            • Damage ControlFocus on Physiology
                                            • Damage Control Patient Selection
                                            • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                            • Questions
                                            • Summary and Conclusions

                                              Breathing All trauma patients need oxygen until proven otherwisebull Thoracic injuries account for

                                              25 of all trauma deathsbull Understand the significance of

                                              patternsndash 1st and 2nd rib fxs abdominal breathing

                                              bull Treat the pneumo before ETTbull Life-threatening thoracic

                                              injuries need to be detected earlyndash Tension pneumondash Massive hemothoracesndash Cardiac tamponadendash Flail chest

                                              1

                                              2

                                              CT Scan for thoracic trauma

                                              An occult pneumothorax seen on a CT scan that was not detected on a plain

                                              anteroposterior supine chest radiograph

                                              bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                                              bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                                              Hemorrhage All trauma patients are bleeding until proven otherwise

                                              bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                                              bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                                              bull Prevent shock by arresting the bleeding

                                              bull Mandates the earliest possible ldquogoal directed therapyrdquo

                                              Hemorrhage PEARLbull Recognize trouble

                                              ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                              increases morbidity and doubles mortality especially in head injured patients

                                              bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                              ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                              Hemorrhage 5 Anatomic Areas of Origin

                                              Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                              Hemorrhage Importance of Lactate amp BD

                                              bull For Resuscitation to Occurndash Adequate perfusion and

                                              ndash Tissue oxygenation must be restored

                                              bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                              ndash Controlling the bleeding

                                              Persistent Acidosis Indicates

                                              bull Continued bleeding

                                              bull Inadequate resuscitation

                                              bull Myocardial dysfunction

                                              dArr

                                              serum pH (735 ndash 745)uArr

                                              base deficit (2 to -2)uArr

                                              serum lactate (04 ndash 18)

                                              Base Deficit Categories

                                              bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                              A base deficit of -6 is a marker of severeinjury amp significant mortality

                                              Uses of Base Deficit in Trauma Care

                                              bull Excellent correlation of base deficit to lactate and pH

                                              bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                              bull Assessing shock and efficacy of resuscitation

                                              bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                              Resuscitation End Points

                                              bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                              ndash Mentation

                                              ndash UO

                                              ndash Labs base deficit serum lactate serum pH

                                              Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                              urine output remain standard of carebull Uncompensated shock requires additional

                                              resuscitationbull However after normalizing the above up to 85 of

                                              severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                              bull Better markers of adequate resuscitation are needed

                                              Goal Directed Therapy PEARLbull Recognize trouble

                                              ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                              ndash Anticoagulantsndash Beta blockers

                                              bull Early invasive monitoringbull Follow resuscitation goals

                                              Optimizing Prehospital Resuscitation

                                              bull Low volume fluid administration in penetrating injuries

                                              bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                              sheetsbinderbull Tourniquetsbull Scoop and run transports

                                              based on ldquogolden hourrdquo

                                              ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                              bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                              bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                              Optimizing ResuscitationOptimizing Resuscitation

                                              Prehospital Topicals 2010 Hemostatic Field Dressing

                                              bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                              bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                              Tourniquets 2010

                                              40

                                              Indications for Tourniquetsbull Stop bleeding when life-

                                              threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                              bull Stop bleeding with traumatic amputation

                                              Intraosseous Infusion Devices 2010

                                              EZ-IO

                                              FAST1

                                              Blood Substitutes 2010

                                              bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                              bull Ready for prime time ndash not yet but soon - maybe

                                              bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                              ndash JAMA - April 28 2008

                                              Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                              bull Direct pressure to all external bleeding

                                              bull Rapid suturing of all scalp and facial wounds

                                              bull Rapid application of ThomasHare Traction splints for femur fx

                                              bull Binder for pelvic fxbull Rapid reduction and pressure

                                              dressings of mangled extremities

                                              Pelvic Binders 2010

                                              Optimizing ED Trauma Resuscitation (cont)

                                              bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                              Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                              bull Use FAST to rapidly detect intra-abdominal fluid

                                              bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                              floor during chest tube insertion

                                              Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                              bull Intervene early in resuscitation to STOP bleeding

                                              bull Conserve blood earlybull Aggressive rapid and efficient operative

                                              interventionsbull Use novel methods to STOP bleeding in the

                                              operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                              coagulopathy

                                              bull Controversialndash Whether to administer type and how much

                                              bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                              Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                              MTP Process Shands at UF

                                              Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                              amp notifies designated RN

                                              Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                              refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                              Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                              runner to BB with cross amp match

                                              MTP runner delivers blood products to designated RN

                                              Ismore MTPneeded

                                              EDOR ICU

                                              Designated RN assures bloodadministered per MD order

                                              Designated RN assures blood administered per MD order

                                              Designated RN sends MTP runner for more blood

                                              MTP site

                                              Ispt to be

                                              transported withblood

                                              Designated RN transportsblood with pt to location(ORICU)

                                              END

                                              END

                                              END

                                              YES NO

                                              YES

                                              NO

                                              ED = Nurse ScribeOR = Circ RN notifies

                                              Charge Nurse

                                              62406

                                              ED Thoracotomy for Moribund Patients

                                              bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                              bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                              bull Aortic cross-clamping

                                              Optimizing Resuscitation Across the Continuum

                                              bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                              triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                              bullbull RegroupRegroup

                                              Damage Control Focus on Physiology

                                              bull Major paradigm shift in operative management of devastating injuries

                                              bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                              temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                              ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                              Damage Control Patient Selectionbull Instability

                                              bull Hypothermia (lt 34deg C)

                                              bull Coagulopathy

                                              bull Acidosis (pHlt 72BD -8)

                                              bull Major traumaAvoid ldquoground zero of damage control

                                              (physiological decompensation)

                                              Neurological All unconscious trauma patients have brain injury until proven otherwise

                                              bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                              bull Avoid hypotension in brain injured patients= poor outcome

                                              bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                              bull Urgent CT and expert neurosurgical care is a must

                                              Questions

                                              Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                              Summary and Conclusionsbull It is truly all about the

                                              patient

                                              bull Team effort and framework is needed by design

                                              bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                              bull Trauma centers save lives

                                              • Welcome to Trauma Tracks
                                              • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                              • OBJECTIVES
                                              • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                              • Current Outcomes for CY 2009
                                              • FRAMEWORK
                                              • ProfileCredentials of a Trauma Patient
                                              • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                              • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                              • Slide Number 10
                                              • Slide Number 11
                                              • Slide Number 12
                                              • Slide Number 13
                                              • Situation Awareness
                                              • Most Potentially Preventable Trauma Deaths are related to
                                              • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                              • Optimizing Resuscitation Across the Continuum
                                              • Airway All trauma patients need oxygen until proven otherwise
                                              • Airway All unstable trauma patients need a definitive airway
                                              • Prehospital Intubation
                                              • Prehospital Intubation
                                              • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                              • Bridge Devices 2010
                                              • Breathing All trauma patients need oxygen until proven otherwise
                                              • CT Scan for thoracic trauma
                                              • Hemorrhage All trauma patients are bleeding until proven otherwise
                                              • Hemorrhage PEARL
                                              • Hemorrhage 5 Anatomic Areas of Origin
                                              • Hemorrhage Importance of Lactate amp BD
                                              • Persistent Acidosis Indicates
                                              • Base Deficit Categories
                                              • Uses of Base Deficit in Trauma Care
                                              • Resuscitation End Points
                                              • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                              • Goal Directed Therapy PEARL
                                              • Optimizing Prehospital Resuscitation
                                              • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                              • PrehospitalTopicals 2010Hemostatic Field Dressing
                                              • Tourniquets 2010
                                              • Indications for Tourniquets
                                              • Intraosseous Infusion Devices 2010
                                              • Blood Substitutes 2010
                                              • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                              • Pelvic Binders 2010
                                              • Optimizing ED Trauma Resuscitation (cont)
                                              • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                              • Slide Number 47
                                              • Slide Number 48
                                              • ED Thoracotomy for Moribund Patients
                                              • Optimizing Resuscitation Across the Continuum
                                              • Damage ControlFocus on Physiology
                                              • Damage Control Patient Selection
                                              • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                              • Questions
                                              • Summary and Conclusions

                                                CT Scan for thoracic trauma

                                                An occult pneumothorax seen on a CT scan that was not detected on a plain

                                                anteroposterior supine chest radiograph

                                                bull Recognize the insensitivity of the AP CXR to detection of pneumothoraces

                                                bull Remarkably large occult pneumothoraces may be present without an obvious anterolateral pleural stripe on AP CXR

                                                Hemorrhage All trauma patients are bleeding until proven otherwise

                                                bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                                                bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                                                bull Prevent shock by arresting the bleeding

                                                bull Mandates the earliest possible ldquogoal directed therapyrdquo

                                                Hemorrhage PEARLbull Recognize trouble

                                                ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                                increases morbidity and doubles mortality especially in head injured patients

                                                bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                                ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                                Hemorrhage 5 Anatomic Areas of Origin

                                                Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                                Hemorrhage Importance of Lactate amp BD

                                                bull For Resuscitation to Occurndash Adequate perfusion and

                                                ndash Tissue oxygenation must be restored

                                                bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                                ndash Controlling the bleeding

                                                Persistent Acidosis Indicates

                                                bull Continued bleeding

                                                bull Inadequate resuscitation

                                                bull Myocardial dysfunction

                                                dArr

                                                serum pH (735 ndash 745)uArr

                                                base deficit (2 to -2)uArr

                                                serum lactate (04 ndash 18)

                                                Base Deficit Categories

                                                bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                                A base deficit of -6 is a marker of severeinjury amp significant mortality

                                                Uses of Base Deficit in Trauma Care

                                                bull Excellent correlation of base deficit to lactate and pH

                                                bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                                bull Assessing shock and efficacy of resuscitation

                                                bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                                Resuscitation End Points

                                                bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                                ndash Mentation

                                                ndash UO

                                                ndash Labs base deficit serum lactate serum pH

                                                Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                                urine output remain standard of carebull Uncompensated shock requires additional

                                                resuscitationbull However after normalizing the above up to 85 of

                                                severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                                bull Better markers of adequate resuscitation are needed

                                                Goal Directed Therapy PEARLbull Recognize trouble

                                                ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                ndash Anticoagulantsndash Beta blockers

                                                bull Early invasive monitoringbull Follow resuscitation goals

                                                Optimizing Prehospital Resuscitation

                                                bull Low volume fluid administration in penetrating injuries

                                                bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                based on ldquogolden hourrdquo

                                                ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                Optimizing ResuscitationOptimizing Resuscitation

                                                Prehospital Topicals 2010 Hemostatic Field Dressing

                                                bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                Tourniquets 2010

                                                40

                                                Indications for Tourniquetsbull Stop bleeding when life-

                                                threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                bull Stop bleeding with traumatic amputation

                                                Intraosseous Infusion Devices 2010

                                                EZ-IO

                                                FAST1

                                                Blood Substitutes 2010

                                                bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                bull Ready for prime time ndash not yet but soon - maybe

                                                bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                ndash JAMA - April 28 2008

                                                Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                bull Direct pressure to all external bleeding

                                                bull Rapid suturing of all scalp and facial wounds

                                                bull Rapid application of ThomasHare Traction splints for femur fx

                                                bull Binder for pelvic fxbull Rapid reduction and pressure

                                                dressings of mangled extremities

                                                Pelvic Binders 2010

                                                Optimizing ED Trauma Resuscitation (cont)

                                                bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                bull Use FAST to rapidly detect intra-abdominal fluid

                                                bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                floor during chest tube insertion

                                                Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                bull Intervene early in resuscitation to STOP bleeding

                                                bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                interventionsbull Use novel methods to STOP bleeding in the

                                                operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                coagulopathy

                                                bull Controversialndash Whether to administer type and how much

                                                bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                MTP Process Shands at UF

                                                Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                amp notifies designated RN

                                                Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                runner to BB with cross amp match

                                                MTP runner delivers blood products to designated RN

                                                Ismore MTPneeded

                                                EDOR ICU

                                                Designated RN assures bloodadministered per MD order

                                                Designated RN assures blood administered per MD order

                                                Designated RN sends MTP runner for more blood

                                                MTP site

                                                Ispt to be

                                                transported withblood

                                                Designated RN transportsblood with pt to location(ORICU)

                                                END

                                                END

                                                END

                                                YES NO

                                                YES

                                                NO

                                                ED = Nurse ScribeOR = Circ RN notifies

                                                Charge Nurse

                                                62406

                                                ED Thoracotomy for Moribund Patients

                                                bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                bull Aortic cross-clamping

                                                Optimizing Resuscitation Across the Continuum

                                                bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                bullbull RegroupRegroup

                                                Damage Control Focus on Physiology

                                                bull Major paradigm shift in operative management of devastating injuries

                                                bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                Damage Control Patient Selectionbull Instability

                                                bull Hypothermia (lt 34deg C)

                                                bull Coagulopathy

                                                bull Acidosis (pHlt 72BD -8)

                                                bull Major traumaAvoid ldquoground zero of damage control

                                                (physiological decompensation)

                                                Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                bull Avoid hypotension in brain injured patients= poor outcome

                                                bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                bull Urgent CT and expert neurosurgical care is a must

                                                Questions

                                                Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                Summary and Conclusionsbull It is truly all about the

                                                patient

                                                bull Team effort and framework is needed by design

                                                bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                bull Trauma centers save lives

                                                • Welcome to Trauma Tracks
                                                • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                • OBJECTIVES
                                                • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                • Current Outcomes for CY 2009
                                                • FRAMEWORK
                                                • ProfileCredentials of a Trauma Patient
                                                • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                • Slide Number 10
                                                • Slide Number 11
                                                • Slide Number 12
                                                • Slide Number 13
                                                • Situation Awareness
                                                • Most Potentially Preventable Trauma Deaths are related to
                                                • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                • Optimizing Resuscitation Across the Continuum
                                                • Airway All trauma patients need oxygen until proven otherwise
                                                • Airway All unstable trauma patients need a definitive airway
                                                • Prehospital Intubation
                                                • Prehospital Intubation
                                                • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                • Bridge Devices 2010
                                                • Breathing All trauma patients need oxygen until proven otherwise
                                                • CT Scan for thoracic trauma
                                                • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                • Hemorrhage PEARL
                                                • Hemorrhage 5 Anatomic Areas of Origin
                                                • Hemorrhage Importance of Lactate amp BD
                                                • Persistent Acidosis Indicates
                                                • Base Deficit Categories
                                                • Uses of Base Deficit in Trauma Care
                                                • Resuscitation End Points
                                                • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                • Goal Directed Therapy PEARL
                                                • Optimizing Prehospital Resuscitation
                                                • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                • Tourniquets 2010
                                                • Indications for Tourniquets
                                                • Intraosseous Infusion Devices 2010
                                                • Blood Substitutes 2010
                                                • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                • Pelvic Binders 2010
                                                • Optimizing ED Trauma Resuscitation (cont)
                                                • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                • Slide Number 47
                                                • Slide Number 48
                                                • ED Thoracotomy for Moribund Patients
                                                • Optimizing Resuscitation Across the Continuum
                                                • Damage ControlFocus on Physiology
                                                • Damage Control Patient Selection
                                                • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                • Questions
                                                • Summary and Conclusions

                                                  Hemorrhage All trauma patients are bleeding until proven otherwise

                                                  bull All unstable trauma patients have a presumed diagnosis of hypovolemia even before a specific diagnosis

                                                  bull Stop the bleeding-- hemorrhage control is much more important than fluid resuscitation

                                                  bull Prevent shock by arresting the bleeding

                                                  bull Mandates the earliest possible ldquogoal directed therapyrdquo

                                                  Hemorrhage PEARLbull Recognize trouble

                                                  ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                                  increases morbidity and doubles mortality especially in head injured patients

                                                  bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                                  ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                                  Hemorrhage 5 Anatomic Areas of Origin

                                                  Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                                  Hemorrhage Importance of Lactate amp BD

                                                  bull For Resuscitation to Occurndash Adequate perfusion and

                                                  ndash Tissue oxygenation must be restored

                                                  bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                                  ndash Controlling the bleeding

                                                  Persistent Acidosis Indicates

                                                  bull Continued bleeding

                                                  bull Inadequate resuscitation

                                                  bull Myocardial dysfunction

                                                  dArr

                                                  serum pH (735 ndash 745)uArr

                                                  base deficit (2 to -2)uArr

                                                  serum lactate (04 ndash 18)

                                                  Base Deficit Categories

                                                  bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                                  A base deficit of -6 is a marker of severeinjury amp significant mortality

                                                  Uses of Base Deficit in Trauma Care

                                                  bull Excellent correlation of base deficit to lactate and pH

                                                  bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                                  bull Assessing shock and efficacy of resuscitation

                                                  bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                                  Resuscitation End Points

                                                  bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                                  ndash Mentation

                                                  ndash UO

                                                  ndash Labs base deficit serum lactate serum pH

                                                  Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                                  urine output remain standard of carebull Uncompensated shock requires additional

                                                  resuscitationbull However after normalizing the above up to 85 of

                                                  severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                                  bull Better markers of adequate resuscitation are needed

                                                  Goal Directed Therapy PEARLbull Recognize trouble

                                                  ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                  ndash Anticoagulantsndash Beta blockers

                                                  bull Early invasive monitoringbull Follow resuscitation goals

                                                  Optimizing Prehospital Resuscitation

                                                  bull Low volume fluid administration in penetrating injuries

                                                  bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                  sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                  based on ldquogolden hourrdquo

                                                  ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                  bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                  bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                  Optimizing ResuscitationOptimizing Resuscitation

                                                  Prehospital Topicals 2010 Hemostatic Field Dressing

                                                  bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                  bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                  Tourniquets 2010

                                                  40

                                                  Indications for Tourniquetsbull Stop bleeding when life-

                                                  threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                  bull Stop bleeding with traumatic amputation

                                                  Intraosseous Infusion Devices 2010

                                                  EZ-IO

                                                  FAST1

                                                  Blood Substitutes 2010

                                                  bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                  bull Ready for prime time ndash not yet but soon - maybe

                                                  bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                  ndash JAMA - April 28 2008

                                                  Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                  bull Direct pressure to all external bleeding

                                                  bull Rapid suturing of all scalp and facial wounds

                                                  bull Rapid application of ThomasHare Traction splints for femur fx

                                                  bull Binder for pelvic fxbull Rapid reduction and pressure

                                                  dressings of mangled extremities

                                                  Pelvic Binders 2010

                                                  Optimizing ED Trauma Resuscitation (cont)

                                                  bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                  Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                  bull Use FAST to rapidly detect intra-abdominal fluid

                                                  bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                  floor during chest tube insertion

                                                  Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                  bull Intervene early in resuscitation to STOP bleeding

                                                  bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                  interventionsbull Use novel methods to STOP bleeding in the

                                                  operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                  coagulopathy

                                                  bull Controversialndash Whether to administer type and how much

                                                  bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                  Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                  MTP Process Shands at UF

                                                  Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                  amp notifies designated RN

                                                  Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                  refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                  Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                  runner to BB with cross amp match

                                                  MTP runner delivers blood products to designated RN

                                                  Ismore MTPneeded

                                                  EDOR ICU

                                                  Designated RN assures bloodadministered per MD order

                                                  Designated RN assures blood administered per MD order

                                                  Designated RN sends MTP runner for more blood

                                                  MTP site

                                                  Ispt to be

                                                  transported withblood

                                                  Designated RN transportsblood with pt to location(ORICU)

                                                  END

                                                  END

                                                  END

                                                  YES NO

                                                  YES

                                                  NO

                                                  ED = Nurse ScribeOR = Circ RN notifies

                                                  Charge Nurse

                                                  62406

                                                  ED Thoracotomy for Moribund Patients

                                                  bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                  bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                  bull Aortic cross-clamping

                                                  Optimizing Resuscitation Across the Continuum

                                                  bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                  triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                  bullbull RegroupRegroup

                                                  Damage Control Focus on Physiology

                                                  bull Major paradigm shift in operative management of devastating injuries

                                                  bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                  temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                  ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                  Damage Control Patient Selectionbull Instability

                                                  bull Hypothermia (lt 34deg C)

                                                  bull Coagulopathy

                                                  bull Acidosis (pHlt 72BD -8)

                                                  bull Major traumaAvoid ldquoground zero of damage control

                                                  (physiological decompensation)

                                                  Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                  bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                  bull Avoid hypotension in brain injured patients= poor outcome

                                                  bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                  bull Urgent CT and expert neurosurgical care is a must

                                                  Questions

                                                  Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                  Summary and Conclusionsbull It is truly all about the

                                                  patient

                                                  bull Team effort and framework is needed by design

                                                  bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                  bull Trauma centers save lives

                                                  • Welcome to Trauma Tracks
                                                  • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                  • OBJECTIVES
                                                  • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                  • Current Outcomes for CY 2009
                                                  • FRAMEWORK
                                                  • ProfileCredentials of a Trauma Patient
                                                  • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                  • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                  • Slide Number 10
                                                  • Slide Number 11
                                                  • Slide Number 12
                                                  • Slide Number 13
                                                  • Situation Awareness
                                                  • Most Potentially Preventable Trauma Deaths are related to
                                                  • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                  • Optimizing Resuscitation Across the Continuum
                                                  • Airway All trauma patients need oxygen until proven otherwise
                                                  • Airway All unstable trauma patients need a definitive airway
                                                  • Prehospital Intubation
                                                  • Prehospital Intubation
                                                  • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                  • Bridge Devices 2010
                                                  • Breathing All trauma patients need oxygen until proven otherwise
                                                  • CT Scan for thoracic trauma
                                                  • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                  • Hemorrhage PEARL
                                                  • Hemorrhage 5 Anatomic Areas of Origin
                                                  • Hemorrhage Importance of Lactate amp BD
                                                  • Persistent Acidosis Indicates
                                                  • Base Deficit Categories
                                                  • Uses of Base Deficit in Trauma Care
                                                  • Resuscitation End Points
                                                  • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                  • Goal Directed Therapy PEARL
                                                  • Optimizing Prehospital Resuscitation
                                                  • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                  • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                  • Tourniquets 2010
                                                  • Indications for Tourniquets
                                                  • Intraosseous Infusion Devices 2010
                                                  • Blood Substitutes 2010
                                                  • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                  • Pelvic Binders 2010
                                                  • Optimizing ED Trauma Resuscitation (cont)
                                                  • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                  • Slide Number 47
                                                  • Slide Number 48
                                                  • ED Thoracotomy for Moribund Patients
                                                  • Optimizing Resuscitation Across the Continuum
                                                  • Damage ControlFocus on Physiology
                                                  • Damage Control Patient Selection
                                                  • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                  • Questions
                                                  • Summary and Conclusions

                                                    Hemorrhage PEARLbull Recognize trouble

                                                    ndash Prehospital hypotension and ED instabilitybull Be aware of ldquoepisodic hypotension (systolic lt 90 mm Hg)rdquo-

                                                    increases morbidity and doubles mortality especially in head injured patients

                                                    bull During the fist 90 minutes in the ED patients who were hypotensive with major abdominal injuries requiring lap sustained an additional 1 increase in mortality for every 3 minutes spent in resuscitation before surgery Clarke JR Trooskin SZ Doshi PJ et al J Trauma 200252420-5

                                                    ndash Truncal GSWndash Pelvic fracturesndash VS Lactate BD

                                                    Hemorrhage 5 Anatomic Areas of Origin

                                                    Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                                    Hemorrhage Importance of Lactate amp BD

                                                    bull For Resuscitation to Occurndash Adequate perfusion and

                                                    ndash Tissue oxygenation must be restored

                                                    bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                                    ndash Controlling the bleeding

                                                    Persistent Acidosis Indicates

                                                    bull Continued bleeding

                                                    bull Inadequate resuscitation

                                                    bull Myocardial dysfunction

                                                    dArr

                                                    serum pH (735 ndash 745)uArr

                                                    base deficit (2 to -2)uArr

                                                    serum lactate (04 ndash 18)

                                                    Base Deficit Categories

                                                    bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                                    A base deficit of -6 is a marker of severeinjury amp significant mortality

                                                    Uses of Base Deficit in Trauma Care

                                                    bull Excellent correlation of base deficit to lactate and pH

                                                    bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                                    bull Assessing shock and efficacy of resuscitation

                                                    bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                                    Resuscitation End Points

                                                    bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                                    ndash Mentation

                                                    ndash UO

                                                    ndash Labs base deficit serum lactate serum pH

                                                    Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                                    urine output remain standard of carebull Uncompensated shock requires additional

                                                    resuscitationbull However after normalizing the above up to 85 of

                                                    severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                                    bull Better markers of adequate resuscitation are needed

                                                    Goal Directed Therapy PEARLbull Recognize trouble

                                                    ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                    ndash Anticoagulantsndash Beta blockers

                                                    bull Early invasive monitoringbull Follow resuscitation goals

                                                    Optimizing Prehospital Resuscitation

                                                    bull Low volume fluid administration in penetrating injuries

                                                    bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                    sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                    based on ldquogolden hourrdquo

                                                    ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                    bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                    bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                    Optimizing ResuscitationOptimizing Resuscitation

                                                    Prehospital Topicals 2010 Hemostatic Field Dressing

                                                    bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                    bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                    Tourniquets 2010

                                                    40

                                                    Indications for Tourniquetsbull Stop bleeding when life-

                                                    threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                    bull Stop bleeding with traumatic amputation

                                                    Intraosseous Infusion Devices 2010

                                                    EZ-IO

                                                    FAST1

                                                    Blood Substitutes 2010

                                                    bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                    bull Ready for prime time ndash not yet but soon - maybe

                                                    bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                    ndash JAMA - April 28 2008

                                                    Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                    bull Direct pressure to all external bleeding

                                                    bull Rapid suturing of all scalp and facial wounds

                                                    bull Rapid application of ThomasHare Traction splints for femur fx

                                                    bull Binder for pelvic fxbull Rapid reduction and pressure

                                                    dressings of mangled extremities

                                                    Pelvic Binders 2010

                                                    Optimizing ED Trauma Resuscitation (cont)

                                                    bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                    Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                    bull Use FAST to rapidly detect intra-abdominal fluid

                                                    bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                    floor during chest tube insertion

                                                    Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                    bull Intervene early in resuscitation to STOP bleeding

                                                    bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                    interventionsbull Use novel methods to STOP bleeding in the

                                                    operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                    coagulopathy

                                                    bull Controversialndash Whether to administer type and how much

                                                    bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                    Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                    MTP Process Shands at UF

                                                    Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                    amp notifies designated RN

                                                    Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                    refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                    Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                    runner to BB with cross amp match

                                                    MTP runner delivers blood products to designated RN

                                                    Ismore MTPneeded

                                                    EDOR ICU

                                                    Designated RN assures bloodadministered per MD order

                                                    Designated RN assures blood administered per MD order

                                                    Designated RN sends MTP runner for more blood

                                                    MTP site

                                                    Ispt to be

                                                    transported withblood

                                                    Designated RN transportsblood with pt to location(ORICU)

                                                    END

                                                    END

                                                    END

                                                    YES NO

                                                    YES

                                                    NO

                                                    ED = Nurse ScribeOR = Circ RN notifies

                                                    Charge Nurse

                                                    62406

                                                    ED Thoracotomy for Moribund Patients

                                                    bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                    bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                    bull Aortic cross-clamping

                                                    Optimizing Resuscitation Across the Continuum

                                                    bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                    triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                    bullbull RegroupRegroup

                                                    Damage Control Focus on Physiology

                                                    bull Major paradigm shift in operative management of devastating injuries

                                                    bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                    temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                    ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                    Damage Control Patient Selectionbull Instability

                                                    bull Hypothermia (lt 34deg C)

                                                    bull Coagulopathy

                                                    bull Acidosis (pHlt 72BD -8)

                                                    bull Major traumaAvoid ldquoground zero of damage control

                                                    (physiological decompensation)

                                                    Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                    bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                    bull Avoid hypotension in brain injured patients= poor outcome

                                                    bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                    bull Urgent CT and expert neurosurgical care is a must

                                                    Questions

                                                    Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                    Summary and Conclusionsbull It is truly all about the

                                                    patient

                                                    bull Team effort and framework is needed by design

                                                    bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                    bull Trauma centers save lives

                                                    • Welcome to Trauma Tracks
                                                    • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                    • OBJECTIVES
                                                    • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                    • Current Outcomes for CY 2009
                                                    • FRAMEWORK
                                                    • ProfileCredentials of a Trauma Patient
                                                    • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                    • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                    • Slide Number 10
                                                    • Slide Number 11
                                                    • Slide Number 12
                                                    • Slide Number 13
                                                    • Situation Awareness
                                                    • Most Potentially Preventable Trauma Deaths are related to
                                                    • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                    • Optimizing Resuscitation Across the Continuum
                                                    • Airway All trauma patients need oxygen until proven otherwise
                                                    • Airway All unstable trauma patients need a definitive airway
                                                    • Prehospital Intubation
                                                    • Prehospital Intubation
                                                    • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                    • Bridge Devices 2010
                                                    • Breathing All trauma patients need oxygen until proven otherwise
                                                    • CT Scan for thoracic trauma
                                                    • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                    • Hemorrhage PEARL
                                                    • Hemorrhage 5 Anatomic Areas of Origin
                                                    • Hemorrhage Importance of Lactate amp BD
                                                    • Persistent Acidosis Indicates
                                                    • Base Deficit Categories
                                                    • Uses of Base Deficit in Trauma Care
                                                    • Resuscitation End Points
                                                    • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                    • Goal Directed Therapy PEARL
                                                    • Optimizing Prehospital Resuscitation
                                                    • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                    • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                    • Tourniquets 2010
                                                    • Indications for Tourniquets
                                                    • Intraosseous Infusion Devices 2010
                                                    • Blood Substitutes 2010
                                                    • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                    • Pelvic Binders 2010
                                                    • Optimizing ED Trauma Resuscitation (cont)
                                                    • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                    • Slide Number 47
                                                    • Slide Number 48
                                                    • ED Thoracotomy for Moribund Patients
                                                    • Optimizing Resuscitation Across the Continuum
                                                    • Damage ControlFocus on Physiology
                                                    • Damage Control Patient Selection
                                                    • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                    • Questions
                                                    • Summary and Conclusions

                                                      Hemorrhage 5 Anatomic Areas of Origin

                                                      Kirkpatrick AW et al Can J Surg 200851(1)57-69

                                                      Hemorrhage Importance of Lactate amp BD

                                                      bull For Resuscitation to Occurndash Adequate perfusion and

                                                      ndash Tissue oxygenation must be restored

                                                      bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                                      ndash Controlling the bleeding

                                                      Persistent Acidosis Indicates

                                                      bull Continued bleeding

                                                      bull Inadequate resuscitation

                                                      bull Myocardial dysfunction

                                                      dArr

                                                      serum pH (735 ndash 745)uArr

                                                      base deficit (2 to -2)uArr

                                                      serum lactate (04 ndash 18)

                                                      Base Deficit Categories

                                                      bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                                      A base deficit of -6 is a marker of severeinjury amp significant mortality

                                                      Uses of Base Deficit in Trauma Care

                                                      bull Excellent correlation of base deficit to lactate and pH

                                                      bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                                      bull Assessing shock and efficacy of resuscitation

                                                      bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                                      Resuscitation End Points

                                                      bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                                      ndash Mentation

                                                      ndash UO

                                                      ndash Labs base deficit serum lactate serum pH

                                                      Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                                      urine output remain standard of carebull Uncompensated shock requires additional

                                                      resuscitationbull However after normalizing the above up to 85 of

                                                      severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                                      bull Better markers of adequate resuscitation are needed

                                                      Goal Directed Therapy PEARLbull Recognize trouble

                                                      ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                      ndash Anticoagulantsndash Beta blockers

                                                      bull Early invasive monitoringbull Follow resuscitation goals

                                                      Optimizing Prehospital Resuscitation

                                                      bull Low volume fluid administration in penetrating injuries

                                                      bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                      sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                      based on ldquogolden hourrdquo

                                                      ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                      bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                      bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                      Optimizing ResuscitationOptimizing Resuscitation

                                                      Prehospital Topicals 2010 Hemostatic Field Dressing

                                                      bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                      bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                      Tourniquets 2010

                                                      40

                                                      Indications for Tourniquetsbull Stop bleeding when life-

                                                      threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                      bull Stop bleeding with traumatic amputation

                                                      Intraosseous Infusion Devices 2010

                                                      EZ-IO

                                                      FAST1

                                                      Blood Substitutes 2010

                                                      bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                      bull Ready for prime time ndash not yet but soon - maybe

                                                      bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                      ndash JAMA - April 28 2008

                                                      Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                      bull Direct pressure to all external bleeding

                                                      bull Rapid suturing of all scalp and facial wounds

                                                      bull Rapid application of ThomasHare Traction splints for femur fx

                                                      bull Binder for pelvic fxbull Rapid reduction and pressure

                                                      dressings of mangled extremities

                                                      Pelvic Binders 2010

                                                      Optimizing ED Trauma Resuscitation (cont)

                                                      bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                      Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                      bull Use FAST to rapidly detect intra-abdominal fluid

                                                      bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                      floor during chest tube insertion

                                                      Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                      bull Intervene early in resuscitation to STOP bleeding

                                                      bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                      interventionsbull Use novel methods to STOP bleeding in the

                                                      operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                      coagulopathy

                                                      bull Controversialndash Whether to administer type and how much

                                                      bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                      Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                      MTP Process Shands at UF

                                                      Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                      amp notifies designated RN

                                                      Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                      refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                      Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                      runner to BB with cross amp match

                                                      MTP runner delivers blood products to designated RN

                                                      Ismore MTPneeded

                                                      EDOR ICU

                                                      Designated RN assures bloodadministered per MD order

                                                      Designated RN assures blood administered per MD order

                                                      Designated RN sends MTP runner for more blood

                                                      MTP site

                                                      Ispt to be

                                                      transported withblood

                                                      Designated RN transportsblood with pt to location(ORICU)

                                                      END

                                                      END

                                                      END

                                                      YES NO

                                                      YES

                                                      NO

                                                      ED = Nurse ScribeOR = Circ RN notifies

                                                      Charge Nurse

                                                      62406

                                                      ED Thoracotomy for Moribund Patients

                                                      bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                      bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                      bull Aortic cross-clamping

                                                      Optimizing Resuscitation Across the Continuum

                                                      bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                      triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                      bullbull RegroupRegroup

                                                      Damage Control Focus on Physiology

                                                      bull Major paradigm shift in operative management of devastating injuries

                                                      bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                      temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                      ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                      Damage Control Patient Selectionbull Instability

                                                      bull Hypothermia (lt 34deg C)

                                                      bull Coagulopathy

                                                      bull Acidosis (pHlt 72BD -8)

                                                      bull Major traumaAvoid ldquoground zero of damage control

                                                      (physiological decompensation)

                                                      Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                      bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                      bull Avoid hypotension in brain injured patients= poor outcome

                                                      bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                      bull Urgent CT and expert neurosurgical care is a must

                                                      Questions

                                                      Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                      Summary and Conclusionsbull It is truly all about the

                                                      patient

                                                      bull Team effort and framework is needed by design

                                                      bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                      bull Trauma centers save lives

                                                      • Welcome to Trauma Tracks
                                                      • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                      • OBJECTIVES
                                                      • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                      • Current Outcomes for CY 2009
                                                      • FRAMEWORK
                                                      • ProfileCredentials of a Trauma Patient
                                                      • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                      • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                      • Slide Number 10
                                                      • Slide Number 11
                                                      • Slide Number 12
                                                      • Slide Number 13
                                                      • Situation Awareness
                                                      • Most Potentially Preventable Trauma Deaths are related to
                                                      • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                      • Optimizing Resuscitation Across the Continuum
                                                      • Airway All trauma patients need oxygen until proven otherwise
                                                      • Airway All unstable trauma patients need a definitive airway
                                                      • Prehospital Intubation
                                                      • Prehospital Intubation
                                                      • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                      • Bridge Devices 2010
                                                      • Breathing All trauma patients need oxygen until proven otherwise
                                                      • CT Scan for thoracic trauma
                                                      • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                      • Hemorrhage PEARL
                                                      • Hemorrhage 5 Anatomic Areas of Origin
                                                      • Hemorrhage Importance of Lactate amp BD
                                                      • Persistent Acidosis Indicates
                                                      • Base Deficit Categories
                                                      • Uses of Base Deficit in Trauma Care
                                                      • Resuscitation End Points
                                                      • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                      • Goal Directed Therapy PEARL
                                                      • Optimizing Prehospital Resuscitation
                                                      • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                      • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                      • Tourniquets 2010
                                                      • Indications for Tourniquets
                                                      • Intraosseous Infusion Devices 2010
                                                      • Blood Substitutes 2010
                                                      • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                      • Pelvic Binders 2010
                                                      • Optimizing ED Trauma Resuscitation (cont)
                                                      • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                      • Slide Number 47
                                                      • Slide Number 48
                                                      • ED Thoracotomy for Moribund Patients
                                                      • Optimizing Resuscitation Across the Continuum
                                                      • Damage ControlFocus on Physiology
                                                      • Damage Control Patient Selection
                                                      • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                      • Questions
                                                      • Summary and Conclusions

                                                        Hemorrhage Importance of Lactate amp BD

                                                        bull For Resuscitation to Occurndash Adequate perfusion and

                                                        ndash Tissue oxygenation must be restored

                                                        bull Measures Directed atndash Enhancing O2 transport and O2 uptake

                                                        ndash Controlling the bleeding

                                                        Persistent Acidosis Indicates

                                                        bull Continued bleeding

                                                        bull Inadequate resuscitation

                                                        bull Myocardial dysfunction

                                                        dArr

                                                        serum pH (735 ndash 745)uArr

                                                        base deficit (2 to -2)uArr

                                                        serum lactate (04 ndash 18)

                                                        Base Deficit Categories

                                                        bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                                        A base deficit of -6 is a marker of severeinjury amp significant mortality

                                                        Uses of Base Deficit in Trauma Care

                                                        bull Excellent correlation of base deficit to lactate and pH

                                                        bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                                        bull Assessing shock and efficacy of resuscitation

                                                        bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                                        Resuscitation End Points

                                                        bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                                        ndash Mentation

                                                        ndash UO

                                                        ndash Labs base deficit serum lactate serum pH

                                                        Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                                        urine output remain standard of carebull Uncompensated shock requires additional

                                                        resuscitationbull However after normalizing the above up to 85 of

                                                        severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                                        bull Better markers of adequate resuscitation are needed

                                                        Goal Directed Therapy PEARLbull Recognize trouble

                                                        ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                        ndash Anticoagulantsndash Beta blockers

                                                        bull Early invasive monitoringbull Follow resuscitation goals

                                                        Optimizing Prehospital Resuscitation

                                                        bull Low volume fluid administration in penetrating injuries

                                                        bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                        sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                        based on ldquogolden hourrdquo

                                                        ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                        bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                        bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                        Optimizing ResuscitationOptimizing Resuscitation

                                                        Prehospital Topicals 2010 Hemostatic Field Dressing

                                                        bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                        bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                        Tourniquets 2010

                                                        40

                                                        Indications for Tourniquetsbull Stop bleeding when life-

                                                        threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                        bull Stop bleeding with traumatic amputation

                                                        Intraosseous Infusion Devices 2010

                                                        EZ-IO

                                                        FAST1

                                                        Blood Substitutes 2010

                                                        bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                        bull Ready for prime time ndash not yet but soon - maybe

                                                        bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                        ndash JAMA - April 28 2008

                                                        Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                        bull Direct pressure to all external bleeding

                                                        bull Rapid suturing of all scalp and facial wounds

                                                        bull Rapid application of ThomasHare Traction splints for femur fx

                                                        bull Binder for pelvic fxbull Rapid reduction and pressure

                                                        dressings of mangled extremities

                                                        Pelvic Binders 2010

                                                        Optimizing ED Trauma Resuscitation (cont)

                                                        bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                        Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                        bull Use FAST to rapidly detect intra-abdominal fluid

                                                        bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                        floor during chest tube insertion

                                                        Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                        bull Intervene early in resuscitation to STOP bleeding

                                                        bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                        interventionsbull Use novel methods to STOP bleeding in the

                                                        operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                        coagulopathy

                                                        bull Controversialndash Whether to administer type and how much

                                                        bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                        Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                        MTP Process Shands at UF

                                                        Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                        amp notifies designated RN

                                                        Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                        refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                        Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                        runner to BB with cross amp match

                                                        MTP runner delivers blood products to designated RN

                                                        Ismore MTPneeded

                                                        EDOR ICU

                                                        Designated RN assures bloodadministered per MD order

                                                        Designated RN assures blood administered per MD order

                                                        Designated RN sends MTP runner for more blood

                                                        MTP site

                                                        Ispt to be

                                                        transported withblood

                                                        Designated RN transportsblood with pt to location(ORICU)

                                                        END

                                                        END

                                                        END

                                                        YES NO

                                                        YES

                                                        NO

                                                        ED = Nurse ScribeOR = Circ RN notifies

                                                        Charge Nurse

                                                        62406

                                                        ED Thoracotomy for Moribund Patients

                                                        bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                        bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                        bull Aortic cross-clamping

                                                        Optimizing Resuscitation Across the Continuum

                                                        bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                        triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                        bullbull RegroupRegroup

                                                        Damage Control Focus on Physiology

                                                        bull Major paradigm shift in operative management of devastating injuries

                                                        bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                        temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                        ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                        Damage Control Patient Selectionbull Instability

                                                        bull Hypothermia (lt 34deg C)

                                                        bull Coagulopathy

                                                        bull Acidosis (pHlt 72BD -8)

                                                        bull Major traumaAvoid ldquoground zero of damage control

                                                        (physiological decompensation)

                                                        Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                        bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                        bull Avoid hypotension in brain injured patients= poor outcome

                                                        bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                        bull Urgent CT and expert neurosurgical care is a must

                                                        Questions

                                                        Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                        Summary and Conclusionsbull It is truly all about the

                                                        patient

                                                        bull Team effort and framework is needed by design

                                                        bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                        bull Trauma centers save lives

                                                        • Welcome to Trauma Tracks
                                                        • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                        • OBJECTIVES
                                                        • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                        • Current Outcomes for CY 2009
                                                        • FRAMEWORK
                                                        • ProfileCredentials of a Trauma Patient
                                                        • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                        • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                        • Slide Number 10
                                                        • Slide Number 11
                                                        • Slide Number 12
                                                        • Slide Number 13
                                                        • Situation Awareness
                                                        • Most Potentially Preventable Trauma Deaths are related to
                                                        • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                        • Optimizing Resuscitation Across the Continuum
                                                        • Airway All trauma patients need oxygen until proven otherwise
                                                        • Airway All unstable trauma patients need a definitive airway
                                                        • Prehospital Intubation
                                                        • Prehospital Intubation
                                                        • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                        • Bridge Devices 2010
                                                        • Breathing All trauma patients need oxygen until proven otherwise
                                                        • CT Scan for thoracic trauma
                                                        • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                        • Hemorrhage PEARL
                                                        • Hemorrhage 5 Anatomic Areas of Origin
                                                        • Hemorrhage Importance of Lactate amp BD
                                                        • Persistent Acidosis Indicates
                                                        • Base Deficit Categories
                                                        • Uses of Base Deficit in Trauma Care
                                                        • Resuscitation End Points
                                                        • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                        • Goal Directed Therapy PEARL
                                                        • Optimizing Prehospital Resuscitation
                                                        • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                        • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                        • Tourniquets 2010
                                                        • Indications for Tourniquets
                                                        • Intraosseous Infusion Devices 2010
                                                        • Blood Substitutes 2010
                                                        • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                        • Pelvic Binders 2010
                                                        • Optimizing ED Trauma Resuscitation (cont)
                                                        • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                        • Slide Number 47
                                                        • Slide Number 48
                                                        • ED Thoracotomy for Moribund Patients
                                                        • Optimizing Resuscitation Across the Continuum
                                                        • Damage ControlFocus on Physiology
                                                        • Damage Control Patient Selection
                                                        • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                        • Questions
                                                        • Summary and Conclusions

                                                          Persistent Acidosis Indicates

                                                          bull Continued bleeding

                                                          bull Inadequate resuscitation

                                                          bull Myocardial dysfunction

                                                          dArr

                                                          serum pH (735 ndash 745)uArr

                                                          base deficit (2 to -2)uArr

                                                          serum lactate (04 ndash 18)

                                                          Base Deficit Categories

                                                          bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                                          A base deficit of -6 is a marker of severeinjury amp significant mortality

                                                          Uses of Base Deficit in Trauma Care

                                                          bull Excellent correlation of base deficit to lactate and pH

                                                          bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                                          bull Assessing shock and efficacy of resuscitation

                                                          bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                                          Resuscitation End Points

                                                          bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                                          ndash Mentation

                                                          ndash UO

                                                          ndash Labs base deficit serum lactate serum pH

                                                          Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                                          urine output remain standard of carebull Uncompensated shock requires additional

                                                          resuscitationbull However after normalizing the above up to 85 of

                                                          severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                                          bull Better markers of adequate resuscitation are needed

                                                          Goal Directed Therapy PEARLbull Recognize trouble

                                                          ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                          ndash Anticoagulantsndash Beta blockers

                                                          bull Early invasive monitoringbull Follow resuscitation goals

                                                          Optimizing Prehospital Resuscitation

                                                          bull Low volume fluid administration in penetrating injuries

                                                          bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                          sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                          based on ldquogolden hourrdquo

                                                          ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                          bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                          bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                          Optimizing ResuscitationOptimizing Resuscitation

                                                          Prehospital Topicals 2010 Hemostatic Field Dressing

                                                          bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                          bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                          Tourniquets 2010

                                                          40

                                                          Indications for Tourniquetsbull Stop bleeding when life-

                                                          threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                          bull Stop bleeding with traumatic amputation

                                                          Intraosseous Infusion Devices 2010

                                                          EZ-IO

                                                          FAST1

                                                          Blood Substitutes 2010

                                                          bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                          bull Ready for prime time ndash not yet but soon - maybe

                                                          bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                          ndash JAMA - April 28 2008

                                                          Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                          bull Direct pressure to all external bleeding

                                                          bull Rapid suturing of all scalp and facial wounds

                                                          bull Rapid application of ThomasHare Traction splints for femur fx

                                                          bull Binder for pelvic fxbull Rapid reduction and pressure

                                                          dressings of mangled extremities

                                                          Pelvic Binders 2010

                                                          Optimizing ED Trauma Resuscitation (cont)

                                                          bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                          Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                          bull Use FAST to rapidly detect intra-abdominal fluid

                                                          bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                          floor during chest tube insertion

                                                          Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                          bull Intervene early in resuscitation to STOP bleeding

                                                          bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                          interventionsbull Use novel methods to STOP bleeding in the

                                                          operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                          coagulopathy

                                                          bull Controversialndash Whether to administer type and how much

                                                          bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                          Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                          MTP Process Shands at UF

                                                          Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                          amp notifies designated RN

                                                          Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                          refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                          Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                          runner to BB with cross amp match

                                                          MTP runner delivers blood products to designated RN

                                                          Ismore MTPneeded

                                                          EDOR ICU

                                                          Designated RN assures bloodadministered per MD order

                                                          Designated RN assures blood administered per MD order

                                                          Designated RN sends MTP runner for more blood

                                                          MTP site

                                                          Ispt to be

                                                          transported withblood

                                                          Designated RN transportsblood with pt to location(ORICU)

                                                          END

                                                          END

                                                          END

                                                          YES NO

                                                          YES

                                                          NO

                                                          ED = Nurse ScribeOR = Circ RN notifies

                                                          Charge Nurse

                                                          62406

                                                          ED Thoracotomy for Moribund Patients

                                                          bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                          bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                          bull Aortic cross-clamping

                                                          Optimizing Resuscitation Across the Continuum

                                                          bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                          triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                          bullbull RegroupRegroup

                                                          Damage Control Focus on Physiology

                                                          bull Major paradigm shift in operative management of devastating injuries

                                                          bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                          temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                          ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                          Damage Control Patient Selectionbull Instability

                                                          bull Hypothermia (lt 34deg C)

                                                          bull Coagulopathy

                                                          bull Acidosis (pHlt 72BD -8)

                                                          bull Major traumaAvoid ldquoground zero of damage control

                                                          (physiological decompensation)

                                                          Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                          bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                          bull Avoid hypotension in brain injured patients= poor outcome

                                                          bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                          bull Urgent CT and expert neurosurgical care is a must

                                                          Questions

                                                          Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                          Summary and Conclusionsbull It is truly all about the

                                                          patient

                                                          bull Team effort and framework is needed by design

                                                          bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                          bull Trauma centers save lives

                                                          • Welcome to Trauma Tracks
                                                          • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                          • OBJECTIVES
                                                          • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                          • Current Outcomes for CY 2009
                                                          • FRAMEWORK
                                                          • ProfileCredentials of a Trauma Patient
                                                          • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                          • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                          • Slide Number 10
                                                          • Slide Number 11
                                                          • Slide Number 12
                                                          • Slide Number 13
                                                          • Situation Awareness
                                                          • Most Potentially Preventable Trauma Deaths are related to
                                                          • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                          • Optimizing Resuscitation Across the Continuum
                                                          • Airway All trauma patients need oxygen until proven otherwise
                                                          • Airway All unstable trauma patients need a definitive airway
                                                          • Prehospital Intubation
                                                          • Prehospital Intubation
                                                          • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                          • Bridge Devices 2010
                                                          • Breathing All trauma patients need oxygen until proven otherwise
                                                          • CT Scan for thoracic trauma
                                                          • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                          • Hemorrhage PEARL
                                                          • Hemorrhage 5 Anatomic Areas of Origin
                                                          • Hemorrhage Importance of Lactate amp BD
                                                          • Persistent Acidosis Indicates
                                                          • Base Deficit Categories
                                                          • Uses of Base Deficit in Trauma Care
                                                          • Resuscitation End Points
                                                          • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                          • Goal Directed Therapy PEARL
                                                          • Optimizing Prehospital Resuscitation
                                                          • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                          • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                          • Tourniquets 2010
                                                          • Indications for Tourniquets
                                                          • Intraosseous Infusion Devices 2010
                                                          • Blood Substitutes 2010
                                                          • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                          • Pelvic Binders 2010
                                                          • Optimizing ED Trauma Resuscitation (cont)
                                                          • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                          • Slide Number 47
                                                          • Slide Number 48
                                                          • ED Thoracotomy for Moribund Patients
                                                          • Optimizing Resuscitation Across the Continuum
                                                          • Damage ControlFocus on Physiology
                                                          • Damage Control Patient Selection
                                                          • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                          • Questions
                                                          • Summary and Conclusions

                                                            Base Deficit Categories

                                                            bull Normal (2 to -2)bull Mild (-3 to -5)bull Moderate (-6 to -9)bull Severe (-10 or higher)

                                                            A base deficit of -6 is a marker of severeinjury amp significant mortality

                                                            Uses of Base Deficit in Trauma Care

                                                            bull Excellent correlation of base deficit to lactate and pH

                                                            bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                                            bull Assessing shock and efficacy of resuscitation

                                                            bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                                            Resuscitation End Points

                                                            bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                                            ndash Mentation

                                                            ndash UO

                                                            ndash Labs base deficit serum lactate serum pH

                                                            Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                                            urine output remain standard of carebull Uncompensated shock requires additional

                                                            resuscitationbull However after normalizing the above up to 85 of

                                                            severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                                            bull Better markers of adequate resuscitation are needed

                                                            Goal Directed Therapy PEARLbull Recognize trouble

                                                            ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                            ndash Anticoagulantsndash Beta blockers

                                                            bull Early invasive monitoringbull Follow resuscitation goals

                                                            Optimizing Prehospital Resuscitation

                                                            bull Low volume fluid administration in penetrating injuries

                                                            bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                            sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                            based on ldquogolden hourrdquo

                                                            ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                            bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                            bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                            Optimizing ResuscitationOptimizing Resuscitation

                                                            Prehospital Topicals 2010 Hemostatic Field Dressing

                                                            bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                            bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                            Tourniquets 2010

                                                            40

                                                            Indications for Tourniquetsbull Stop bleeding when life-

                                                            threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                            bull Stop bleeding with traumatic amputation

                                                            Intraosseous Infusion Devices 2010

                                                            EZ-IO

                                                            FAST1

                                                            Blood Substitutes 2010

                                                            bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                            bull Ready for prime time ndash not yet but soon - maybe

                                                            bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                            ndash JAMA - April 28 2008

                                                            Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                            bull Direct pressure to all external bleeding

                                                            bull Rapid suturing of all scalp and facial wounds

                                                            bull Rapid application of ThomasHare Traction splints for femur fx

                                                            bull Binder for pelvic fxbull Rapid reduction and pressure

                                                            dressings of mangled extremities

                                                            Pelvic Binders 2010

                                                            Optimizing ED Trauma Resuscitation (cont)

                                                            bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                            Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                            bull Use FAST to rapidly detect intra-abdominal fluid

                                                            bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                            floor during chest tube insertion

                                                            Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                            bull Intervene early in resuscitation to STOP bleeding

                                                            bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                            interventionsbull Use novel methods to STOP bleeding in the

                                                            operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                            coagulopathy

                                                            bull Controversialndash Whether to administer type and how much

                                                            bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                            Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                            MTP Process Shands at UF

                                                            Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                            amp notifies designated RN

                                                            Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                            refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                            Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                            runner to BB with cross amp match

                                                            MTP runner delivers blood products to designated RN

                                                            Ismore MTPneeded

                                                            EDOR ICU

                                                            Designated RN assures bloodadministered per MD order

                                                            Designated RN assures blood administered per MD order

                                                            Designated RN sends MTP runner for more blood

                                                            MTP site

                                                            Ispt to be

                                                            transported withblood

                                                            Designated RN transportsblood with pt to location(ORICU)

                                                            END

                                                            END

                                                            END

                                                            YES NO

                                                            YES

                                                            NO

                                                            ED = Nurse ScribeOR = Circ RN notifies

                                                            Charge Nurse

                                                            62406

                                                            ED Thoracotomy for Moribund Patients

                                                            bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                            bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                            bull Aortic cross-clamping

                                                            Optimizing Resuscitation Across the Continuum

                                                            bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                            triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                            bullbull RegroupRegroup

                                                            Damage Control Focus on Physiology

                                                            bull Major paradigm shift in operative management of devastating injuries

                                                            bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                            temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                            ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                            Damage Control Patient Selectionbull Instability

                                                            bull Hypothermia (lt 34deg C)

                                                            bull Coagulopathy

                                                            bull Acidosis (pHlt 72BD -8)

                                                            bull Major traumaAvoid ldquoground zero of damage control

                                                            (physiological decompensation)

                                                            Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                            bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                            bull Avoid hypotension in brain injured patients= poor outcome

                                                            bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                            bull Urgent CT and expert neurosurgical care is a must

                                                            Questions

                                                            Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                            Summary and Conclusionsbull It is truly all about the

                                                            patient

                                                            bull Team effort and framework is needed by design

                                                            bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                            bull Trauma centers save lives

                                                            • Welcome to Trauma Tracks
                                                            • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                            • OBJECTIVES
                                                            • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                            • Current Outcomes for CY 2009
                                                            • FRAMEWORK
                                                            • ProfileCredentials of a Trauma Patient
                                                            • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                            • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                            • Slide Number 10
                                                            • Slide Number 11
                                                            • Slide Number 12
                                                            • Slide Number 13
                                                            • Situation Awareness
                                                            • Most Potentially Preventable Trauma Deaths are related to
                                                            • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                            • Optimizing Resuscitation Across the Continuum
                                                            • Airway All trauma patients need oxygen until proven otherwise
                                                            • Airway All unstable trauma patients need a definitive airway
                                                            • Prehospital Intubation
                                                            • Prehospital Intubation
                                                            • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                            • Bridge Devices 2010
                                                            • Breathing All trauma patients need oxygen until proven otherwise
                                                            • CT Scan for thoracic trauma
                                                            • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                            • Hemorrhage PEARL
                                                            • Hemorrhage 5 Anatomic Areas of Origin
                                                            • Hemorrhage Importance of Lactate amp BD
                                                            • Persistent Acidosis Indicates
                                                            • Base Deficit Categories
                                                            • Uses of Base Deficit in Trauma Care
                                                            • Resuscitation End Points
                                                            • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                            • Goal Directed Therapy PEARL
                                                            • Optimizing Prehospital Resuscitation
                                                            • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                            • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                            • Tourniquets 2010
                                                            • Indications for Tourniquets
                                                            • Intraosseous Infusion Devices 2010
                                                            • Blood Substitutes 2010
                                                            • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                            • Pelvic Binders 2010
                                                            • Optimizing ED Trauma Resuscitation (cont)
                                                            • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                            • Slide Number 47
                                                            • Slide Number 48
                                                            • ED Thoracotomy for Moribund Patients
                                                            • Optimizing Resuscitation Across the Continuum
                                                            • Damage ControlFocus on Physiology
                                                            • Damage Control Patient Selection
                                                            • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                            • Questions
                                                            • Summary and Conclusions

                                                              Uses of Base Deficit in Trauma Care

                                                              bull Excellent correlation of base deficit to lactate and pH

                                                              bull Normalizes rapidly with adequate resuscitation and control of hemorrhage

                                                              bull Assessing shock and efficacy of resuscitation

                                                              bull Predictingndash abdominal injuryndash transfusion requirementndash complications (RDS MODS)ndash mortality

                                                              Resuscitation End Points

                                                              bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                                              ndash Mentation

                                                              ndash UO

                                                              ndash Labs base deficit serum lactate serum pH

                                                              Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                                              urine output remain standard of carebull Uncompensated shock requires additional

                                                              resuscitationbull However after normalizing the above up to 85 of

                                                              severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                                              bull Better markers of adequate resuscitation are needed

                                                              Goal Directed Therapy PEARLbull Recognize trouble

                                                              ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                              ndash Anticoagulantsndash Beta blockers

                                                              bull Early invasive monitoringbull Follow resuscitation goals

                                                              Optimizing Prehospital Resuscitation

                                                              bull Low volume fluid administration in penetrating injuries

                                                              bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                              sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                              based on ldquogolden hourrdquo

                                                              ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                              bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                              bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                              Optimizing ResuscitationOptimizing Resuscitation

                                                              Prehospital Topicals 2010 Hemostatic Field Dressing

                                                              bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                              bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                              Tourniquets 2010

                                                              40

                                                              Indications for Tourniquetsbull Stop bleeding when life-

                                                              threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                              bull Stop bleeding with traumatic amputation

                                                              Intraosseous Infusion Devices 2010

                                                              EZ-IO

                                                              FAST1

                                                              Blood Substitutes 2010

                                                              bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                              bull Ready for prime time ndash not yet but soon - maybe

                                                              bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                              ndash JAMA - April 28 2008

                                                              Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                              bull Direct pressure to all external bleeding

                                                              bull Rapid suturing of all scalp and facial wounds

                                                              bull Rapid application of ThomasHare Traction splints for femur fx

                                                              bull Binder for pelvic fxbull Rapid reduction and pressure

                                                              dressings of mangled extremities

                                                              Pelvic Binders 2010

                                                              Optimizing ED Trauma Resuscitation (cont)

                                                              bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                              Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                              bull Use FAST to rapidly detect intra-abdominal fluid

                                                              bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                              floor during chest tube insertion

                                                              Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                              bull Intervene early in resuscitation to STOP bleeding

                                                              bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                              interventionsbull Use novel methods to STOP bleeding in the

                                                              operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                              coagulopathy

                                                              bull Controversialndash Whether to administer type and how much

                                                              bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                              Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                              MTP Process Shands at UF

                                                              Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                              amp notifies designated RN

                                                              Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                              refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                              Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                              runner to BB with cross amp match

                                                              MTP runner delivers blood products to designated RN

                                                              Ismore MTPneeded

                                                              EDOR ICU

                                                              Designated RN assures bloodadministered per MD order

                                                              Designated RN assures blood administered per MD order

                                                              Designated RN sends MTP runner for more blood

                                                              MTP site

                                                              Ispt to be

                                                              transported withblood

                                                              Designated RN transportsblood with pt to location(ORICU)

                                                              END

                                                              END

                                                              END

                                                              YES NO

                                                              YES

                                                              NO

                                                              ED = Nurse ScribeOR = Circ RN notifies

                                                              Charge Nurse

                                                              62406

                                                              ED Thoracotomy for Moribund Patients

                                                              bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                              bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                              bull Aortic cross-clamping

                                                              Optimizing Resuscitation Across the Continuum

                                                              bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                              triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                              bullbull RegroupRegroup

                                                              Damage Control Focus on Physiology

                                                              bull Major paradigm shift in operative management of devastating injuries

                                                              bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                              temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                              ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                              Damage Control Patient Selectionbull Instability

                                                              bull Hypothermia (lt 34deg C)

                                                              bull Coagulopathy

                                                              bull Acidosis (pHlt 72BD -8)

                                                              bull Major traumaAvoid ldquoground zero of damage control

                                                              (physiological decompensation)

                                                              Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                              bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                              bull Avoid hypotension in brain injured patients= poor outcome

                                                              bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                              bull Urgent CT and expert neurosurgical care is a must

                                                              Questions

                                                              Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                              Summary and Conclusionsbull It is truly all about the

                                                              patient

                                                              bull Team effort and framework is needed by design

                                                              bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                              bull Trauma centers save lives

                                                              • Welcome to Trauma Tracks
                                                              • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                              • OBJECTIVES
                                                              • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                              • Current Outcomes for CY 2009
                                                              • FRAMEWORK
                                                              • ProfileCredentials of a Trauma Patient
                                                              • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                              • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                              • Slide Number 10
                                                              • Slide Number 11
                                                              • Slide Number 12
                                                              • Slide Number 13
                                                              • Situation Awareness
                                                              • Most Potentially Preventable Trauma Deaths are related to
                                                              • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                              • Optimizing Resuscitation Across the Continuum
                                                              • Airway All trauma patients need oxygen until proven otherwise
                                                              • Airway All unstable trauma patients need a definitive airway
                                                              • Prehospital Intubation
                                                              • Prehospital Intubation
                                                              • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                              • Bridge Devices 2010
                                                              • Breathing All trauma patients need oxygen until proven otherwise
                                                              • CT Scan for thoracic trauma
                                                              • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                              • Hemorrhage PEARL
                                                              • Hemorrhage 5 Anatomic Areas of Origin
                                                              • Hemorrhage Importance of Lactate amp BD
                                                              • Persistent Acidosis Indicates
                                                              • Base Deficit Categories
                                                              • Uses of Base Deficit in Trauma Care
                                                              • Resuscitation End Points
                                                              • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                              • Goal Directed Therapy PEARL
                                                              • Optimizing Prehospital Resuscitation
                                                              • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                              • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                              • Tourniquets 2010
                                                              • Indications for Tourniquets
                                                              • Intraosseous Infusion Devices 2010
                                                              • Blood Substitutes 2010
                                                              • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                              • Pelvic Binders 2010
                                                              • Optimizing ED Trauma Resuscitation (cont)
                                                              • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                              • Slide Number 47
                                                              • Slide Number 48
                                                              • ED Thoracotomy for Moribund Patients
                                                              • Optimizing Resuscitation Across the Continuum
                                                              • Damage ControlFocus on Physiology
                                                              • Damage Control Patient Selection
                                                              • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                              • Questions
                                                              • Summary and Conclusions

                                                                Resuscitation End Points

                                                                bull Re-evaluation of resuscitation end pointsndash BP HR pulse pressure

                                                                ndash Mentation

                                                                ndash UO

                                                                ndash Labs base deficit serum lactate serum pH

                                                                Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                                                urine output remain standard of carebull Uncompensated shock requires additional

                                                                resuscitationbull However after normalizing the above up to 85 of

                                                                severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                                                bull Better markers of adequate resuscitation are needed

                                                                Goal Directed Therapy PEARLbull Recognize trouble

                                                                ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                                ndash Anticoagulantsndash Beta blockers

                                                                bull Early invasive monitoringbull Follow resuscitation goals

                                                                Optimizing Prehospital Resuscitation

                                                                bull Low volume fluid administration in penetrating injuries

                                                                bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                                sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                                based on ldquogolden hourrdquo

                                                                ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                                bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                                bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                                Optimizing ResuscitationOptimizing Resuscitation

                                                                Prehospital Topicals 2010 Hemostatic Field Dressing

                                                                bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                                bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                                Tourniquets 2010

                                                                40

                                                                Indications for Tourniquetsbull Stop bleeding when life-

                                                                threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                                bull Stop bleeding with traumatic amputation

                                                                Intraosseous Infusion Devices 2010

                                                                EZ-IO

                                                                FAST1

                                                                Blood Substitutes 2010

                                                                bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                                bull Ready for prime time ndash not yet but soon - maybe

                                                                bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                                ndash JAMA - April 28 2008

                                                                Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                bull Direct pressure to all external bleeding

                                                                bull Rapid suturing of all scalp and facial wounds

                                                                bull Rapid application of ThomasHare Traction splints for femur fx

                                                                bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                dressings of mangled extremities

                                                                Pelvic Binders 2010

                                                                Optimizing ED Trauma Resuscitation (cont)

                                                                bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                bull Use FAST to rapidly detect intra-abdominal fluid

                                                                bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                floor during chest tube insertion

                                                                Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                bull Intervene early in resuscitation to STOP bleeding

                                                                bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                interventionsbull Use novel methods to STOP bleeding in the

                                                                operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                coagulopathy

                                                                bull Controversialndash Whether to administer type and how much

                                                                bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                MTP Process Shands at UF

                                                                Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                amp notifies designated RN

                                                                Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                runner to BB with cross amp match

                                                                MTP runner delivers blood products to designated RN

                                                                Ismore MTPneeded

                                                                EDOR ICU

                                                                Designated RN assures bloodadministered per MD order

                                                                Designated RN assures blood administered per MD order

                                                                Designated RN sends MTP runner for more blood

                                                                MTP site

                                                                Ispt to be

                                                                transported withblood

                                                                Designated RN transportsblood with pt to location(ORICU)

                                                                END

                                                                END

                                                                END

                                                                YES NO

                                                                YES

                                                                NO

                                                                ED = Nurse ScribeOR = Circ RN notifies

                                                                Charge Nurse

                                                                62406

                                                                ED Thoracotomy for Moribund Patients

                                                                bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                bull Aortic cross-clamping

                                                                Optimizing Resuscitation Across the Continuum

                                                                bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                bullbull RegroupRegroup

                                                                Damage Control Focus on Physiology

                                                                bull Major paradigm shift in operative management of devastating injuries

                                                                bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                Damage Control Patient Selectionbull Instability

                                                                bull Hypothermia (lt 34deg C)

                                                                bull Coagulopathy

                                                                bull Acidosis (pHlt 72BD -8)

                                                                bull Major traumaAvoid ldquoground zero of damage control

                                                                (physiological decompensation)

                                                                Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                bull Avoid hypotension in brain injured patients= poor outcome

                                                                bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                bull Urgent CT and expert neurosurgical care is a must

                                                                Questions

                                                                Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                Summary and Conclusionsbull It is truly all about the

                                                                patient

                                                                bull Team effort and framework is needed by design

                                                                bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                bull Trauma centers save lives

                                                                • Welcome to Trauma Tracks
                                                                • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                • OBJECTIVES
                                                                • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                • Current Outcomes for CY 2009
                                                                • FRAMEWORK
                                                                • ProfileCredentials of a Trauma Patient
                                                                • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                • Slide Number 10
                                                                • Slide Number 11
                                                                • Slide Number 12
                                                                • Slide Number 13
                                                                • Situation Awareness
                                                                • Most Potentially Preventable Trauma Deaths are related to
                                                                • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                • Optimizing Resuscitation Across the Continuum
                                                                • Airway All trauma patients need oxygen until proven otherwise
                                                                • Airway All unstable trauma patients need a definitive airway
                                                                • Prehospital Intubation
                                                                • Prehospital Intubation
                                                                • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                • Bridge Devices 2010
                                                                • Breathing All trauma patients need oxygen until proven otherwise
                                                                • CT Scan for thoracic trauma
                                                                • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                • Hemorrhage PEARL
                                                                • Hemorrhage 5 Anatomic Areas of Origin
                                                                • Hemorrhage Importance of Lactate amp BD
                                                                • Persistent Acidosis Indicates
                                                                • Base Deficit Categories
                                                                • Uses of Base Deficit in Trauma Care
                                                                • Resuscitation End Points
                                                                • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                • Goal Directed Therapy PEARL
                                                                • Optimizing Prehospital Resuscitation
                                                                • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                • Tourniquets 2010
                                                                • Indications for Tourniquets
                                                                • Intraosseous Infusion Devices 2010
                                                                • Blood Substitutes 2010
                                                                • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                • Pelvic Binders 2010
                                                                • Optimizing ED Trauma Resuscitation (cont)
                                                                • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                • Slide Number 47
                                                                • Slide Number 48
                                                                • ED Thoracotomy for Moribund Patients
                                                                • Optimizing Resuscitation Across the Continuum
                                                                • Damage ControlFocus on Physiology
                                                                • Damage Control Patient Selection
                                                                • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                • Questions
                                                                • Summary and Conclusions

                                                                  Eastern Association for the Surgery of Trauma Practice Guidelines ldquoEndpoints of Resuscitationrdquobull wwweastorgbull Traditional markers of blood pressure heart rate

                                                                  urine output remain standard of carebull Uncompensated shock requires additional

                                                                  resuscitationbull However after normalizing the above up to 85 of

                                                                  severely injured patients have evidence of inadequate tissue perfusion based on ongoing metabolic acidosis or evidence of gastric mucosal ischemia

                                                                  bull Better markers of adequate resuscitation are needed

                                                                  Goal Directed Therapy PEARLbull Recognize trouble

                                                                  ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                                  ndash Anticoagulantsndash Beta blockers

                                                                  bull Early invasive monitoringbull Follow resuscitation goals

                                                                  Optimizing Prehospital Resuscitation

                                                                  bull Low volume fluid administration in penetrating injuries

                                                                  bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                                  sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                                  based on ldquogolden hourrdquo

                                                                  ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                                  bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                                  bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                                  Optimizing ResuscitationOptimizing Resuscitation

                                                                  Prehospital Topicals 2010 Hemostatic Field Dressing

                                                                  bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                                  bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                                  Tourniquets 2010

                                                                  40

                                                                  Indications for Tourniquetsbull Stop bleeding when life-

                                                                  threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                                  bull Stop bleeding with traumatic amputation

                                                                  Intraosseous Infusion Devices 2010

                                                                  EZ-IO

                                                                  FAST1

                                                                  Blood Substitutes 2010

                                                                  bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                                  bull Ready for prime time ndash not yet but soon - maybe

                                                                  bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                                  ndash JAMA - April 28 2008

                                                                  Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                  bull Direct pressure to all external bleeding

                                                                  bull Rapid suturing of all scalp and facial wounds

                                                                  bull Rapid application of ThomasHare Traction splints for femur fx

                                                                  bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                  dressings of mangled extremities

                                                                  Pelvic Binders 2010

                                                                  Optimizing ED Trauma Resuscitation (cont)

                                                                  bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                  Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                  bull Use FAST to rapidly detect intra-abdominal fluid

                                                                  bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                  floor during chest tube insertion

                                                                  Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                  bull Intervene early in resuscitation to STOP bleeding

                                                                  bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                  interventionsbull Use novel methods to STOP bleeding in the

                                                                  operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                  coagulopathy

                                                                  bull Controversialndash Whether to administer type and how much

                                                                  bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                  Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                  MTP Process Shands at UF

                                                                  Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                  amp notifies designated RN

                                                                  Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                  refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                  Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                  runner to BB with cross amp match

                                                                  MTP runner delivers blood products to designated RN

                                                                  Ismore MTPneeded

                                                                  EDOR ICU

                                                                  Designated RN assures bloodadministered per MD order

                                                                  Designated RN assures blood administered per MD order

                                                                  Designated RN sends MTP runner for more blood

                                                                  MTP site

                                                                  Ispt to be

                                                                  transported withblood

                                                                  Designated RN transportsblood with pt to location(ORICU)

                                                                  END

                                                                  END

                                                                  END

                                                                  YES NO

                                                                  YES

                                                                  NO

                                                                  ED = Nurse ScribeOR = Circ RN notifies

                                                                  Charge Nurse

                                                                  62406

                                                                  ED Thoracotomy for Moribund Patients

                                                                  bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                  bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                  bull Aortic cross-clamping

                                                                  Optimizing Resuscitation Across the Continuum

                                                                  bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                  triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                  bullbull RegroupRegroup

                                                                  Damage Control Focus on Physiology

                                                                  bull Major paradigm shift in operative management of devastating injuries

                                                                  bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                  temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                  ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                  Damage Control Patient Selectionbull Instability

                                                                  bull Hypothermia (lt 34deg C)

                                                                  bull Coagulopathy

                                                                  bull Acidosis (pHlt 72BD -8)

                                                                  bull Major traumaAvoid ldquoground zero of damage control

                                                                  (physiological decompensation)

                                                                  Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                  bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                  bull Avoid hypotension in brain injured patients= poor outcome

                                                                  bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                  bull Urgent CT and expert neurosurgical care is a must

                                                                  Questions

                                                                  Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                  Summary and Conclusionsbull It is truly all about the

                                                                  patient

                                                                  bull Team effort and framework is needed by design

                                                                  bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                  bull Trauma centers save lives

                                                                  • Welcome to Trauma Tracks
                                                                  • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                  • OBJECTIVES
                                                                  • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                  • Current Outcomes for CY 2009
                                                                  • FRAMEWORK
                                                                  • ProfileCredentials of a Trauma Patient
                                                                  • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                  • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                  • Slide Number 10
                                                                  • Slide Number 11
                                                                  • Slide Number 12
                                                                  • Slide Number 13
                                                                  • Situation Awareness
                                                                  • Most Potentially Preventable Trauma Deaths are related to
                                                                  • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                  • Optimizing Resuscitation Across the Continuum
                                                                  • Airway All trauma patients need oxygen until proven otherwise
                                                                  • Airway All unstable trauma patients need a definitive airway
                                                                  • Prehospital Intubation
                                                                  • Prehospital Intubation
                                                                  • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                  • Bridge Devices 2010
                                                                  • Breathing All trauma patients need oxygen until proven otherwise
                                                                  • CT Scan for thoracic trauma
                                                                  • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                  • Hemorrhage PEARL
                                                                  • Hemorrhage 5 Anatomic Areas of Origin
                                                                  • Hemorrhage Importance of Lactate amp BD
                                                                  • Persistent Acidosis Indicates
                                                                  • Base Deficit Categories
                                                                  • Uses of Base Deficit in Trauma Care
                                                                  • Resuscitation End Points
                                                                  • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                  • Goal Directed Therapy PEARL
                                                                  • Optimizing Prehospital Resuscitation
                                                                  • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                  • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                  • Tourniquets 2010
                                                                  • Indications for Tourniquets
                                                                  • Intraosseous Infusion Devices 2010
                                                                  • Blood Substitutes 2010
                                                                  • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                  • Pelvic Binders 2010
                                                                  • Optimizing ED Trauma Resuscitation (cont)
                                                                  • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                  • Slide Number 47
                                                                  • Slide Number 48
                                                                  • ED Thoracotomy for Moribund Patients
                                                                  • Optimizing Resuscitation Across the Continuum
                                                                  • Damage ControlFocus on Physiology
                                                                  • Damage Control Patient Selection
                                                                  • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                  • Questions
                                                                  • Summary and Conclusions

                                                                    Goal Directed Therapy PEARLbull Recognize trouble

                                                                    ndash High risk patientsbull Geriatric patientsbull Pediatric patientsbull Pregnant women

                                                                    ndash Anticoagulantsndash Beta blockers

                                                                    bull Early invasive monitoringbull Follow resuscitation goals

                                                                    Optimizing Prehospital Resuscitation

                                                                    bull Low volume fluid administration in penetrating injuries

                                                                    bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                                    sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                                    based on ldquogolden hourrdquo

                                                                    ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                                    bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                                    bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                                    Optimizing ResuscitationOptimizing Resuscitation

                                                                    Prehospital Topicals 2010 Hemostatic Field Dressing

                                                                    bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                                    bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                                    Tourniquets 2010

                                                                    40

                                                                    Indications for Tourniquetsbull Stop bleeding when life-

                                                                    threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                                    bull Stop bleeding with traumatic amputation

                                                                    Intraosseous Infusion Devices 2010

                                                                    EZ-IO

                                                                    FAST1

                                                                    Blood Substitutes 2010

                                                                    bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                                    bull Ready for prime time ndash not yet but soon - maybe

                                                                    bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                                    ndash JAMA - April 28 2008

                                                                    Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                    bull Direct pressure to all external bleeding

                                                                    bull Rapid suturing of all scalp and facial wounds

                                                                    bull Rapid application of ThomasHare Traction splints for femur fx

                                                                    bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                    dressings of mangled extremities

                                                                    Pelvic Binders 2010

                                                                    Optimizing ED Trauma Resuscitation (cont)

                                                                    bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                    Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                    bull Use FAST to rapidly detect intra-abdominal fluid

                                                                    bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                    floor during chest tube insertion

                                                                    Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                    bull Intervene early in resuscitation to STOP bleeding

                                                                    bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                    interventionsbull Use novel methods to STOP bleeding in the

                                                                    operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                    coagulopathy

                                                                    bull Controversialndash Whether to administer type and how much

                                                                    bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                    Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                    MTP Process Shands at UF

                                                                    Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                    amp notifies designated RN

                                                                    Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                    refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                    Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                    runner to BB with cross amp match

                                                                    MTP runner delivers blood products to designated RN

                                                                    Ismore MTPneeded

                                                                    EDOR ICU

                                                                    Designated RN assures bloodadministered per MD order

                                                                    Designated RN assures blood administered per MD order

                                                                    Designated RN sends MTP runner for more blood

                                                                    MTP site

                                                                    Ispt to be

                                                                    transported withblood

                                                                    Designated RN transportsblood with pt to location(ORICU)

                                                                    END

                                                                    END

                                                                    END

                                                                    YES NO

                                                                    YES

                                                                    NO

                                                                    ED = Nurse ScribeOR = Circ RN notifies

                                                                    Charge Nurse

                                                                    62406

                                                                    ED Thoracotomy for Moribund Patients

                                                                    bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                    bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                    bull Aortic cross-clamping

                                                                    Optimizing Resuscitation Across the Continuum

                                                                    bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                    triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                    bullbull RegroupRegroup

                                                                    Damage Control Focus on Physiology

                                                                    bull Major paradigm shift in operative management of devastating injuries

                                                                    bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                    temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                    ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                    Damage Control Patient Selectionbull Instability

                                                                    bull Hypothermia (lt 34deg C)

                                                                    bull Coagulopathy

                                                                    bull Acidosis (pHlt 72BD -8)

                                                                    bull Major traumaAvoid ldquoground zero of damage control

                                                                    (physiological decompensation)

                                                                    Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                    bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                    bull Avoid hypotension in brain injured patients= poor outcome

                                                                    bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                    bull Urgent CT and expert neurosurgical care is a must

                                                                    Questions

                                                                    Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                    Summary and Conclusionsbull It is truly all about the

                                                                    patient

                                                                    bull Team effort and framework is needed by design

                                                                    bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                    bull Trauma centers save lives

                                                                    • Welcome to Trauma Tracks
                                                                    • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                    • OBJECTIVES
                                                                    • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                    • Current Outcomes for CY 2009
                                                                    • FRAMEWORK
                                                                    • ProfileCredentials of a Trauma Patient
                                                                    • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                    • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                    • Slide Number 10
                                                                    • Slide Number 11
                                                                    • Slide Number 12
                                                                    • Slide Number 13
                                                                    • Situation Awareness
                                                                    • Most Potentially Preventable Trauma Deaths are related to
                                                                    • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                    • Optimizing Resuscitation Across the Continuum
                                                                    • Airway All trauma patients need oxygen until proven otherwise
                                                                    • Airway All unstable trauma patients need a definitive airway
                                                                    • Prehospital Intubation
                                                                    • Prehospital Intubation
                                                                    • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                    • Bridge Devices 2010
                                                                    • Breathing All trauma patients need oxygen until proven otherwise
                                                                    • CT Scan for thoracic trauma
                                                                    • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                    • Hemorrhage PEARL
                                                                    • Hemorrhage 5 Anatomic Areas of Origin
                                                                    • Hemorrhage Importance of Lactate amp BD
                                                                    • Persistent Acidosis Indicates
                                                                    • Base Deficit Categories
                                                                    • Uses of Base Deficit in Trauma Care
                                                                    • Resuscitation End Points
                                                                    • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                    • Goal Directed Therapy PEARL
                                                                    • Optimizing Prehospital Resuscitation
                                                                    • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                    • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                    • Tourniquets 2010
                                                                    • Indications for Tourniquets
                                                                    • Intraosseous Infusion Devices 2010
                                                                    • Blood Substitutes 2010
                                                                    • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                    • Pelvic Binders 2010
                                                                    • Optimizing ED Trauma Resuscitation (cont)
                                                                    • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                    • Slide Number 47
                                                                    • Slide Number 48
                                                                    • ED Thoracotomy for Moribund Patients
                                                                    • Optimizing Resuscitation Across the Continuum
                                                                    • Damage ControlFocus on Physiology
                                                                    • Damage Control Patient Selection
                                                                    • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                    • Questions
                                                                    • Summary and Conclusions

                                                                      Optimizing Prehospital Resuscitation

                                                                      bull Low volume fluid administration in penetrating injuries

                                                                      bull Splint all fracturesbull Dress all woundsbull Wrap pelvic fractures with

                                                                      sheetsbinderbull Tourniquetsbull Scoop and run transports

                                                                      based on ldquogolden hourrdquo

                                                                      ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                                      bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                                      bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                                      Optimizing ResuscitationOptimizing Resuscitation

                                                                      Prehospital Topicals 2010 Hemostatic Field Dressing

                                                                      bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                                      bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                                      Tourniquets 2010

                                                                      40

                                                                      Indications for Tourniquetsbull Stop bleeding when life-

                                                                      threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                                      bull Stop bleeding with traumatic amputation

                                                                      Intraosseous Infusion Devices 2010

                                                                      EZ-IO

                                                                      FAST1

                                                                      Blood Substitutes 2010

                                                                      bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                                      bull Ready for prime time ndash not yet but soon - maybe

                                                                      bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                                      ndash JAMA - April 28 2008

                                                                      Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                      bull Direct pressure to all external bleeding

                                                                      bull Rapid suturing of all scalp and facial wounds

                                                                      bull Rapid application of ThomasHare Traction splints for femur fx

                                                                      bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                      dressings of mangled extremities

                                                                      Pelvic Binders 2010

                                                                      Optimizing ED Trauma Resuscitation (cont)

                                                                      bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                      Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                      bull Use FAST to rapidly detect intra-abdominal fluid

                                                                      bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                      floor during chest tube insertion

                                                                      Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                      bull Intervene early in resuscitation to STOP bleeding

                                                                      bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                      interventionsbull Use novel methods to STOP bleeding in the

                                                                      operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                      coagulopathy

                                                                      bull Controversialndash Whether to administer type and how much

                                                                      bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                      Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                      MTP Process Shands at UF

                                                                      Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                      amp notifies designated RN

                                                                      Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                      refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                      Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                      runner to BB with cross amp match

                                                                      MTP runner delivers blood products to designated RN

                                                                      Ismore MTPneeded

                                                                      EDOR ICU

                                                                      Designated RN assures bloodadministered per MD order

                                                                      Designated RN assures blood administered per MD order

                                                                      Designated RN sends MTP runner for more blood

                                                                      MTP site

                                                                      Ispt to be

                                                                      transported withblood

                                                                      Designated RN transportsblood with pt to location(ORICU)

                                                                      END

                                                                      END

                                                                      END

                                                                      YES NO

                                                                      YES

                                                                      NO

                                                                      ED = Nurse ScribeOR = Circ RN notifies

                                                                      Charge Nurse

                                                                      62406

                                                                      ED Thoracotomy for Moribund Patients

                                                                      bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                      bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                      bull Aortic cross-clamping

                                                                      Optimizing Resuscitation Across the Continuum

                                                                      bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                      triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                      bullbull RegroupRegroup

                                                                      Damage Control Focus on Physiology

                                                                      bull Major paradigm shift in operative management of devastating injuries

                                                                      bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                      temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                      ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                      Damage Control Patient Selectionbull Instability

                                                                      bull Hypothermia (lt 34deg C)

                                                                      bull Coagulopathy

                                                                      bull Acidosis (pHlt 72BD -8)

                                                                      bull Major traumaAvoid ldquoground zero of damage control

                                                                      (physiological decompensation)

                                                                      Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                      bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                      bull Avoid hypotension in brain injured patients= poor outcome

                                                                      bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                      bull Urgent CT and expert neurosurgical care is a must

                                                                      Questions

                                                                      Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                      Summary and Conclusionsbull It is truly all about the

                                                                      patient

                                                                      bull Team effort and framework is needed by design

                                                                      bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                      bull Trauma centers save lives

                                                                      • Welcome to Trauma Tracks
                                                                      • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                      • OBJECTIVES
                                                                      • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                      • Current Outcomes for CY 2009
                                                                      • FRAMEWORK
                                                                      • ProfileCredentials of a Trauma Patient
                                                                      • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                      • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                      • Slide Number 10
                                                                      • Slide Number 11
                                                                      • Slide Number 12
                                                                      • Slide Number 13
                                                                      • Situation Awareness
                                                                      • Most Potentially Preventable Trauma Deaths are related to
                                                                      • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                      • Optimizing Resuscitation Across the Continuum
                                                                      • Airway All trauma patients need oxygen until proven otherwise
                                                                      • Airway All unstable trauma patients need a definitive airway
                                                                      • Prehospital Intubation
                                                                      • Prehospital Intubation
                                                                      • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                      • Bridge Devices 2010
                                                                      • Breathing All trauma patients need oxygen until proven otherwise
                                                                      • CT Scan for thoracic trauma
                                                                      • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                      • Hemorrhage PEARL
                                                                      • Hemorrhage 5 Anatomic Areas of Origin
                                                                      • Hemorrhage Importance of Lactate amp BD
                                                                      • Persistent Acidosis Indicates
                                                                      • Base Deficit Categories
                                                                      • Uses of Base Deficit in Trauma Care
                                                                      • Resuscitation End Points
                                                                      • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                      • Goal Directed Therapy PEARL
                                                                      • Optimizing Prehospital Resuscitation
                                                                      • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                      • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                      • Tourniquets 2010
                                                                      • Indications for Tourniquets
                                                                      • Intraosseous Infusion Devices 2010
                                                                      • Blood Substitutes 2010
                                                                      • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                      • Pelvic Binders 2010
                                                                      • Optimizing ED Trauma Resuscitation (cont)
                                                                      • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                      • Slide Number 47
                                                                      • Slide Number 48
                                                                      • ED Thoracotomy for Moribund Patients
                                                                      • Optimizing Resuscitation Across the Continuum
                                                                      • Damage ControlFocus on Physiology
                                                                      • Damage Control Patient Selection
                                                                      • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                      • Questions
                                                                      • Summary and Conclusions

                                                                        ldquoto resuscitate or not to resuscitaterdquo (hypotensive resuscitation)

                                                                        bull Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries ldquoa prospective randomized trial rdquoBickell WH Wall MJ Pepe PE et al NEJM 19943311105-1109

                                                                        bull Hypotensive resuscitation during active hemorrhage impact on in-hospital mortality Dutton RP Mackenzie CF Scalea TM J Trauma 200252(6)1141-6

                                                                        Optimizing ResuscitationOptimizing Resuscitation

                                                                        Prehospital Topicals 2010 Hemostatic Field Dressing

                                                                        bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                                        bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                                        Tourniquets 2010

                                                                        40

                                                                        Indications for Tourniquetsbull Stop bleeding when life-

                                                                        threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                                        bull Stop bleeding with traumatic amputation

                                                                        Intraosseous Infusion Devices 2010

                                                                        EZ-IO

                                                                        FAST1

                                                                        Blood Substitutes 2010

                                                                        bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                                        bull Ready for prime time ndash not yet but soon - maybe

                                                                        bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                                        ndash JAMA - April 28 2008

                                                                        Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                        bull Direct pressure to all external bleeding

                                                                        bull Rapid suturing of all scalp and facial wounds

                                                                        bull Rapid application of ThomasHare Traction splints for femur fx

                                                                        bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                        dressings of mangled extremities

                                                                        Pelvic Binders 2010

                                                                        Optimizing ED Trauma Resuscitation (cont)

                                                                        bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                        Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                        bull Use FAST to rapidly detect intra-abdominal fluid

                                                                        bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                        floor during chest tube insertion

                                                                        Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                        bull Intervene early in resuscitation to STOP bleeding

                                                                        bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                        interventionsbull Use novel methods to STOP bleeding in the

                                                                        operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                        coagulopathy

                                                                        bull Controversialndash Whether to administer type and how much

                                                                        bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                        Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                        MTP Process Shands at UF

                                                                        Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                        amp notifies designated RN

                                                                        Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                        refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                        Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                        runner to BB with cross amp match

                                                                        MTP runner delivers blood products to designated RN

                                                                        Ismore MTPneeded

                                                                        EDOR ICU

                                                                        Designated RN assures bloodadministered per MD order

                                                                        Designated RN assures blood administered per MD order

                                                                        Designated RN sends MTP runner for more blood

                                                                        MTP site

                                                                        Ispt to be

                                                                        transported withblood

                                                                        Designated RN transportsblood with pt to location(ORICU)

                                                                        END

                                                                        END

                                                                        END

                                                                        YES NO

                                                                        YES

                                                                        NO

                                                                        ED = Nurse ScribeOR = Circ RN notifies

                                                                        Charge Nurse

                                                                        62406

                                                                        ED Thoracotomy for Moribund Patients

                                                                        bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                        bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                        bull Aortic cross-clamping

                                                                        Optimizing Resuscitation Across the Continuum

                                                                        bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                        triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                        bullbull RegroupRegroup

                                                                        Damage Control Focus on Physiology

                                                                        bull Major paradigm shift in operative management of devastating injuries

                                                                        bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                        temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                        ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                        Damage Control Patient Selectionbull Instability

                                                                        bull Hypothermia (lt 34deg C)

                                                                        bull Coagulopathy

                                                                        bull Acidosis (pHlt 72BD -8)

                                                                        bull Major traumaAvoid ldquoground zero of damage control

                                                                        (physiological decompensation)

                                                                        Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                        bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                        bull Avoid hypotension in brain injured patients= poor outcome

                                                                        bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                        bull Urgent CT and expert neurosurgical care is a must

                                                                        Questions

                                                                        Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                        Summary and Conclusionsbull It is truly all about the

                                                                        patient

                                                                        bull Team effort and framework is needed by design

                                                                        bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                        bull Trauma centers save lives

                                                                        • Welcome to Trauma Tracks
                                                                        • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                        • OBJECTIVES
                                                                        • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                        • Current Outcomes for CY 2009
                                                                        • FRAMEWORK
                                                                        • ProfileCredentials of a Trauma Patient
                                                                        • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                        • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                        • Slide Number 10
                                                                        • Slide Number 11
                                                                        • Slide Number 12
                                                                        • Slide Number 13
                                                                        • Situation Awareness
                                                                        • Most Potentially Preventable Trauma Deaths are related to
                                                                        • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                        • Optimizing Resuscitation Across the Continuum
                                                                        • Airway All trauma patients need oxygen until proven otherwise
                                                                        • Airway All unstable trauma patients need a definitive airway
                                                                        • Prehospital Intubation
                                                                        • Prehospital Intubation
                                                                        • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                        • Bridge Devices 2010
                                                                        • Breathing All trauma patients need oxygen until proven otherwise
                                                                        • CT Scan for thoracic trauma
                                                                        • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                        • Hemorrhage PEARL
                                                                        • Hemorrhage 5 Anatomic Areas of Origin
                                                                        • Hemorrhage Importance of Lactate amp BD
                                                                        • Persistent Acidosis Indicates
                                                                        • Base Deficit Categories
                                                                        • Uses of Base Deficit in Trauma Care
                                                                        • Resuscitation End Points
                                                                        • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                        • Goal Directed Therapy PEARL
                                                                        • Optimizing Prehospital Resuscitation
                                                                        • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                        • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                        • Tourniquets 2010
                                                                        • Indications for Tourniquets
                                                                        • Intraosseous Infusion Devices 2010
                                                                        • Blood Substitutes 2010
                                                                        • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                        • Pelvic Binders 2010
                                                                        • Optimizing ED Trauma Resuscitation (cont)
                                                                        • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                        • Slide Number 47
                                                                        • Slide Number 48
                                                                        • ED Thoracotomy for Moribund Patients
                                                                        • Optimizing Resuscitation Across the Continuum
                                                                        • Damage ControlFocus on Physiology
                                                                        • Damage Control Patient Selection
                                                                        • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                        • Questions
                                                                        • Summary and Conclusions

                                                                          Prehospital Topicals 2010 Hemostatic Field Dressing

                                                                          bullbull ChitosanChitosan-- derived from chitin from shellfish amp crab shells

                                                                          bullbull QuickClotQuickClot-- powder from powder from volcanic materialvolcanic material

                                                                          Tourniquets 2010

                                                                          40

                                                                          Indications for Tourniquetsbull Stop bleeding when life-

                                                                          threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                                          bull Stop bleeding with traumatic amputation

                                                                          Intraosseous Infusion Devices 2010

                                                                          EZ-IO

                                                                          FAST1

                                                                          Blood Substitutes 2010

                                                                          bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                                          bull Ready for prime time ndash not yet but soon - maybe

                                                                          bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                                          ndash JAMA - April 28 2008

                                                                          Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                          bull Direct pressure to all external bleeding

                                                                          bull Rapid suturing of all scalp and facial wounds

                                                                          bull Rapid application of ThomasHare Traction splints for femur fx

                                                                          bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                          dressings of mangled extremities

                                                                          Pelvic Binders 2010

                                                                          Optimizing ED Trauma Resuscitation (cont)

                                                                          bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                          Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                          bull Use FAST to rapidly detect intra-abdominal fluid

                                                                          bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                          floor during chest tube insertion

                                                                          Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                          bull Intervene early in resuscitation to STOP bleeding

                                                                          bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                          interventionsbull Use novel methods to STOP bleeding in the

                                                                          operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                          coagulopathy

                                                                          bull Controversialndash Whether to administer type and how much

                                                                          bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                          Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                          MTP Process Shands at UF

                                                                          Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                          amp notifies designated RN

                                                                          Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                          refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                          Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                          runner to BB with cross amp match

                                                                          MTP runner delivers blood products to designated RN

                                                                          Ismore MTPneeded

                                                                          EDOR ICU

                                                                          Designated RN assures bloodadministered per MD order

                                                                          Designated RN assures blood administered per MD order

                                                                          Designated RN sends MTP runner for more blood

                                                                          MTP site

                                                                          Ispt to be

                                                                          transported withblood

                                                                          Designated RN transportsblood with pt to location(ORICU)

                                                                          END

                                                                          END

                                                                          END

                                                                          YES NO

                                                                          YES

                                                                          NO

                                                                          ED = Nurse ScribeOR = Circ RN notifies

                                                                          Charge Nurse

                                                                          62406

                                                                          ED Thoracotomy for Moribund Patients

                                                                          bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                          bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                          bull Aortic cross-clamping

                                                                          Optimizing Resuscitation Across the Continuum

                                                                          bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                          triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                          bullbull RegroupRegroup

                                                                          Damage Control Focus on Physiology

                                                                          bull Major paradigm shift in operative management of devastating injuries

                                                                          bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                          temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                          ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                          Damage Control Patient Selectionbull Instability

                                                                          bull Hypothermia (lt 34deg C)

                                                                          bull Coagulopathy

                                                                          bull Acidosis (pHlt 72BD -8)

                                                                          bull Major traumaAvoid ldquoground zero of damage control

                                                                          (physiological decompensation)

                                                                          Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                          bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                          bull Avoid hypotension in brain injured patients= poor outcome

                                                                          bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                          bull Urgent CT and expert neurosurgical care is a must

                                                                          Questions

                                                                          Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                          Summary and Conclusionsbull It is truly all about the

                                                                          patient

                                                                          bull Team effort and framework is needed by design

                                                                          bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                          bull Trauma centers save lives

                                                                          • Welcome to Trauma Tracks
                                                                          • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                          • OBJECTIVES
                                                                          • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                          • Current Outcomes for CY 2009
                                                                          • FRAMEWORK
                                                                          • ProfileCredentials of a Trauma Patient
                                                                          • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                          • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                          • Slide Number 10
                                                                          • Slide Number 11
                                                                          • Slide Number 12
                                                                          • Slide Number 13
                                                                          • Situation Awareness
                                                                          • Most Potentially Preventable Trauma Deaths are related to
                                                                          • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                          • Optimizing Resuscitation Across the Continuum
                                                                          • Airway All trauma patients need oxygen until proven otherwise
                                                                          • Airway All unstable trauma patients need a definitive airway
                                                                          • Prehospital Intubation
                                                                          • Prehospital Intubation
                                                                          • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                          • Bridge Devices 2010
                                                                          • Breathing All trauma patients need oxygen until proven otherwise
                                                                          • CT Scan for thoracic trauma
                                                                          • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                          • Hemorrhage PEARL
                                                                          • Hemorrhage 5 Anatomic Areas of Origin
                                                                          • Hemorrhage Importance of Lactate amp BD
                                                                          • Persistent Acidosis Indicates
                                                                          • Base Deficit Categories
                                                                          • Uses of Base Deficit in Trauma Care
                                                                          • Resuscitation End Points
                                                                          • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                          • Goal Directed Therapy PEARL
                                                                          • Optimizing Prehospital Resuscitation
                                                                          • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                          • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                          • Tourniquets 2010
                                                                          • Indications for Tourniquets
                                                                          • Intraosseous Infusion Devices 2010
                                                                          • Blood Substitutes 2010
                                                                          • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                          • Pelvic Binders 2010
                                                                          • Optimizing ED Trauma Resuscitation (cont)
                                                                          • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                          • Slide Number 47
                                                                          • Slide Number 48
                                                                          • ED Thoracotomy for Moribund Patients
                                                                          • Optimizing Resuscitation Across the Continuum
                                                                          • Damage ControlFocus on Physiology
                                                                          • Damage Control Patient Selection
                                                                          • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                          • Questions
                                                                          • Summary and Conclusions

                                                                            Tourniquets 2010

                                                                            40

                                                                            Indications for Tourniquetsbull Stop bleeding when life-

                                                                            threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                                            bull Stop bleeding with traumatic amputation

                                                                            Intraosseous Infusion Devices 2010

                                                                            EZ-IO

                                                                            FAST1

                                                                            Blood Substitutes 2010

                                                                            bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                                            bull Ready for prime time ndash not yet but soon - maybe

                                                                            bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                                            ndash JAMA - April 28 2008

                                                                            Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                            bull Direct pressure to all external bleeding

                                                                            bull Rapid suturing of all scalp and facial wounds

                                                                            bull Rapid application of ThomasHare Traction splints for femur fx

                                                                            bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                            dressings of mangled extremities

                                                                            Pelvic Binders 2010

                                                                            Optimizing ED Trauma Resuscitation (cont)

                                                                            bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                            Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                            bull Use FAST to rapidly detect intra-abdominal fluid

                                                                            bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                            floor during chest tube insertion

                                                                            Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                            bull Intervene early in resuscitation to STOP bleeding

                                                                            bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                            interventionsbull Use novel methods to STOP bleeding in the

                                                                            operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                            coagulopathy

                                                                            bull Controversialndash Whether to administer type and how much

                                                                            bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                            Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                            MTP Process Shands at UF

                                                                            Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                            amp notifies designated RN

                                                                            Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                            refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                            Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                            runner to BB with cross amp match

                                                                            MTP runner delivers blood products to designated RN

                                                                            Ismore MTPneeded

                                                                            EDOR ICU

                                                                            Designated RN assures bloodadministered per MD order

                                                                            Designated RN assures blood administered per MD order

                                                                            Designated RN sends MTP runner for more blood

                                                                            MTP site

                                                                            Ispt to be

                                                                            transported withblood

                                                                            Designated RN transportsblood with pt to location(ORICU)

                                                                            END

                                                                            END

                                                                            END

                                                                            YES NO

                                                                            YES

                                                                            NO

                                                                            ED = Nurse ScribeOR = Circ RN notifies

                                                                            Charge Nurse

                                                                            62406

                                                                            ED Thoracotomy for Moribund Patients

                                                                            bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                            bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                            bull Aortic cross-clamping

                                                                            Optimizing Resuscitation Across the Continuum

                                                                            bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                            triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                            bullbull RegroupRegroup

                                                                            Damage Control Focus on Physiology

                                                                            bull Major paradigm shift in operative management of devastating injuries

                                                                            bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                            temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                            ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                            Damage Control Patient Selectionbull Instability

                                                                            bull Hypothermia (lt 34deg C)

                                                                            bull Coagulopathy

                                                                            bull Acidosis (pHlt 72BD -8)

                                                                            bull Major traumaAvoid ldquoground zero of damage control

                                                                            (physiological decompensation)

                                                                            Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                            bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                            bull Avoid hypotension in brain injured patients= poor outcome

                                                                            bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                            bull Urgent CT and expert neurosurgical care is a must

                                                                            Questions

                                                                            Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                            Summary and Conclusionsbull It is truly all about the

                                                                            patient

                                                                            bull Team effort and framework is needed by design

                                                                            bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                            bull Trauma centers save lives

                                                                            • Welcome to Trauma Tracks
                                                                            • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                            • OBJECTIVES
                                                                            • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                            • Current Outcomes for CY 2009
                                                                            • FRAMEWORK
                                                                            • ProfileCredentials of a Trauma Patient
                                                                            • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                            • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                            • Slide Number 10
                                                                            • Slide Number 11
                                                                            • Slide Number 12
                                                                            • Slide Number 13
                                                                            • Situation Awareness
                                                                            • Most Potentially Preventable Trauma Deaths are related to
                                                                            • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                            • Optimizing Resuscitation Across the Continuum
                                                                            • Airway All trauma patients need oxygen until proven otherwise
                                                                            • Airway All unstable trauma patients need a definitive airway
                                                                            • Prehospital Intubation
                                                                            • Prehospital Intubation
                                                                            • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                            • Bridge Devices 2010
                                                                            • Breathing All trauma patients need oxygen until proven otherwise
                                                                            • CT Scan for thoracic trauma
                                                                            • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                            • Hemorrhage PEARL
                                                                            • Hemorrhage 5 Anatomic Areas of Origin
                                                                            • Hemorrhage Importance of Lactate amp BD
                                                                            • Persistent Acidosis Indicates
                                                                            • Base Deficit Categories
                                                                            • Uses of Base Deficit in Trauma Care
                                                                            • Resuscitation End Points
                                                                            • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                            • Goal Directed Therapy PEARL
                                                                            • Optimizing Prehospital Resuscitation
                                                                            • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                            • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                            • Tourniquets 2010
                                                                            • Indications for Tourniquets
                                                                            • Intraosseous Infusion Devices 2010
                                                                            • Blood Substitutes 2010
                                                                            • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                            • Pelvic Binders 2010
                                                                            • Optimizing ED Trauma Resuscitation (cont)
                                                                            • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                            • Slide Number 47
                                                                            • Slide Number 48
                                                                            • ED Thoracotomy for Moribund Patients
                                                                            • Optimizing Resuscitation Across the Continuum
                                                                            • Damage ControlFocus on Physiology
                                                                            • Damage Control Patient Selection
                                                                            • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                            • Questions
                                                                            • Summary and Conclusions

                                                                              40

                                                                              Indications for Tourniquetsbull Stop bleeding when life-

                                                                              threatening limb hemorrhage otherwise uncontrollable such as mangled extremity

                                                                              bull Stop bleeding with traumatic amputation

                                                                              Intraosseous Infusion Devices 2010

                                                                              EZ-IO

                                                                              FAST1

                                                                              Blood Substitutes 2010

                                                                              bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                                              bull Ready for prime time ndash not yet but soon - maybe

                                                                              bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                                              ndash JAMA - April 28 2008

                                                                              Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                              bull Direct pressure to all external bleeding

                                                                              bull Rapid suturing of all scalp and facial wounds

                                                                              bull Rapid application of ThomasHare Traction splints for femur fx

                                                                              bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                              dressings of mangled extremities

                                                                              Pelvic Binders 2010

                                                                              Optimizing ED Trauma Resuscitation (cont)

                                                                              bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                              Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                              bull Use FAST to rapidly detect intra-abdominal fluid

                                                                              bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                              floor during chest tube insertion

                                                                              Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                              bull Intervene early in resuscitation to STOP bleeding

                                                                              bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                              interventionsbull Use novel methods to STOP bleeding in the

                                                                              operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                              coagulopathy

                                                                              bull Controversialndash Whether to administer type and how much

                                                                              bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                              Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                              MTP Process Shands at UF

                                                                              Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                              amp notifies designated RN

                                                                              Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                              refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                              Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                              runner to BB with cross amp match

                                                                              MTP runner delivers blood products to designated RN

                                                                              Ismore MTPneeded

                                                                              EDOR ICU

                                                                              Designated RN assures bloodadministered per MD order

                                                                              Designated RN assures blood administered per MD order

                                                                              Designated RN sends MTP runner for more blood

                                                                              MTP site

                                                                              Ispt to be

                                                                              transported withblood

                                                                              Designated RN transportsblood with pt to location(ORICU)

                                                                              END

                                                                              END

                                                                              END

                                                                              YES NO

                                                                              YES

                                                                              NO

                                                                              ED = Nurse ScribeOR = Circ RN notifies

                                                                              Charge Nurse

                                                                              62406

                                                                              ED Thoracotomy for Moribund Patients

                                                                              bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                              bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                              bull Aortic cross-clamping

                                                                              Optimizing Resuscitation Across the Continuum

                                                                              bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                              triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                              bullbull RegroupRegroup

                                                                              Damage Control Focus on Physiology

                                                                              bull Major paradigm shift in operative management of devastating injuries

                                                                              bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                              temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                              ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                              Damage Control Patient Selectionbull Instability

                                                                              bull Hypothermia (lt 34deg C)

                                                                              bull Coagulopathy

                                                                              bull Acidosis (pHlt 72BD -8)

                                                                              bull Major traumaAvoid ldquoground zero of damage control

                                                                              (physiological decompensation)

                                                                              Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                              bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                              bull Avoid hypotension in brain injured patients= poor outcome

                                                                              bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                              bull Urgent CT and expert neurosurgical care is a must

                                                                              Questions

                                                                              Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                              Summary and Conclusionsbull It is truly all about the

                                                                              patient

                                                                              bull Team effort and framework is needed by design

                                                                              bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                              bull Trauma centers save lives

                                                                              • Welcome to Trauma Tracks
                                                                              • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                              • OBJECTIVES
                                                                              • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                              • Current Outcomes for CY 2009
                                                                              • FRAMEWORK
                                                                              • ProfileCredentials of a Trauma Patient
                                                                              • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                              • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                              • Slide Number 10
                                                                              • Slide Number 11
                                                                              • Slide Number 12
                                                                              • Slide Number 13
                                                                              • Situation Awareness
                                                                              • Most Potentially Preventable Trauma Deaths are related to
                                                                              • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                              • Optimizing Resuscitation Across the Continuum
                                                                              • Airway All trauma patients need oxygen until proven otherwise
                                                                              • Airway All unstable trauma patients need a definitive airway
                                                                              • Prehospital Intubation
                                                                              • Prehospital Intubation
                                                                              • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                              • Bridge Devices 2010
                                                                              • Breathing All trauma patients need oxygen until proven otherwise
                                                                              • CT Scan for thoracic trauma
                                                                              • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                              • Hemorrhage PEARL
                                                                              • Hemorrhage 5 Anatomic Areas of Origin
                                                                              • Hemorrhage Importance of Lactate amp BD
                                                                              • Persistent Acidosis Indicates
                                                                              • Base Deficit Categories
                                                                              • Uses of Base Deficit in Trauma Care
                                                                              • Resuscitation End Points
                                                                              • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                              • Goal Directed Therapy PEARL
                                                                              • Optimizing Prehospital Resuscitation
                                                                              • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                              • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                              • Tourniquets 2010
                                                                              • Indications for Tourniquets
                                                                              • Intraosseous Infusion Devices 2010
                                                                              • Blood Substitutes 2010
                                                                              • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                              • Pelvic Binders 2010
                                                                              • Optimizing ED Trauma Resuscitation (cont)
                                                                              • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                              • Slide Number 47
                                                                              • Slide Number 48
                                                                              • ED Thoracotomy for Moribund Patients
                                                                              • Optimizing Resuscitation Across the Continuum
                                                                              • Damage ControlFocus on Physiology
                                                                              • Damage Control Patient Selection
                                                                              • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                              • Questions
                                                                              • Summary and Conclusions

                                                                                Intraosseous Infusion Devices 2010

                                                                                EZ-IO

                                                                                FAST1

                                                                                Blood Substitutes 2010

                                                                                bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                                                bull Ready for prime time ndash not yet but soon - maybe

                                                                                bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                                                ndash JAMA - April 28 2008

                                                                                Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                                bull Direct pressure to all external bleeding

                                                                                bull Rapid suturing of all scalp and facial wounds

                                                                                bull Rapid application of ThomasHare Traction splints for femur fx

                                                                                bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                                dressings of mangled extremities

                                                                                Pelvic Binders 2010

                                                                                Optimizing ED Trauma Resuscitation (cont)

                                                                                bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                                Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                                bull Use FAST to rapidly detect intra-abdominal fluid

                                                                                bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                                floor during chest tube insertion

                                                                                Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                                bull Intervene early in resuscitation to STOP bleeding

                                                                                bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                                interventionsbull Use novel methods to STOP bleeding in the

                                                                                operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                                coagulopathy

                                                                                bull Controversialndash Whether to administer type and how much

                                                                                bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                                Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                                MTP Process Shands at UF

                                                                                Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                                amp notifies designated RN

                                                                                Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                                refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                                Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                                runner to BB with cross amp match

                                                                                MTP runner delivers blood products to designated RN

                                                                                Ismore MTPneeded

                                                                                EDOR ICU

                                                                                Designated RN assures bloodadministered per MD order

                                                                                Designated RN assures blood administered per MD order

                                                                                Designated RN sends MTP runner for more blood

                                                                                MTP site

                                                                                Ispt to be

                                                                                transported withblood

                                                                                Designated RN transportsblood with pt to location(ORICU)

                                                                                END

                                                                                END

                                                                                END

                                                                                YES NO

                                                                                YES

                                                                                NO

                                                                                ED = Nurse ScribeOR = Circ RN notifies

                                                                                Charge Nurse

                                                                                62406

                                                                                ED Thoracotomy for Moribund Patients

                                                                                bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                                bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                                bull Aortic cross-clamping

                                                                                Optimizing Resuscitation Across the Continuum

                                                                                bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                                triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                                bullbull RegroupRegroup

                                                                                Damage Control Focus on Physiology

                                                                                bull Major paradigm shift in operative management of devastating injuries

                                                                                bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                Damage Control Patient Selectionbull Instability

                                                                                bull Hypothermia (lt 34deg C)

                                                                                bull Coagulopathy

                                                                                bull Acidosis (pHlt 72BD -8)

                                                                                bull Major traumaAvoid ldquoground zero of damage control

                                                                                (physiological decompensation)

                                                                                Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                bull Avoid hypotension in brain injured patients= poor outcome

                                                                                bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                bull Urgent CT and expert neurosurgical care is a must

                                                                                Questions

                                                                                Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                Summary and Conclusionsbull It is truly all about the

                                                                                patient

                                                                                bull Team effort and framework is needed by design

                                                                                bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                bull Trauma centers save lives

                                                                                • Welcome to Trauma Tracks
                                                                                • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                • OBJECTIVES
                                                                                • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                • Current Outcomes for CY 2009
                                                                                • FRAMEWORK
                                                                                • ProfileCredentials of a Trauma Patient
                                                                                • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                • Slide Number 10
                                                                                • Slide Number 11
                                                                                • Slide Number 12
                                                                                • Slide Number 13
                                                                                • Situation Awareness
                                                                                • Most Potentially Preventable Trauma Deaths are related to
                                                                                • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                • Optimizing Resuscitation Across the Continuum
                                                                                • Airway All trauma patients need oxygen until proven otherwise
                                                                                • Airway All unstable trauma patients need a definitive airway
                                                                                • Prehospital Intubation
                                                                                • Prehospital Intubation
                                                                                • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                • Bridge Devices 2010
                                                                                • Breathing All trauma patients need oxygen until proven otherwise
                                                                                • CT Scan for thoracic trauma
                                                                                • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                • Hemorrhage PEARL
                                                                                • Hemorrhage 5 Anatomic Areas of Origin
                                                                                • Hemorrhage Importance of Lactate amp BD
                                                                                • Persistent Acidosis Indicates
                                                                                • Base Deficit Categories
                                                                                • Uses of Base Deficit in Trauma Care
                                                                                • Resuscitation End Points
                                                                                • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                • Goal Directed Therapy PEARL
                                                                                • Optimizing Prehospital Resuscitation
                                                                                • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                • Tourniquets 2010
                                                                                • Indications for Tourniquets
                                                                                • Intraosseous Infusion Devices 2010
                                                                                • Blood Substitutes 2010
                                                                                • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                • Pelvic Binders 2010
                                                                                • Optimizing ED Trauma Resuscitation (cont)
                                                                                • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                • Slide Number 47
                                                                                • Slide Number 48
                                                                                • ED Thoracotomy for Moribund Patients
                                                                                • Optimizing Resuscitation Across the Continuum
                                                                                • Damage ControlFocus on Physiology
                                                                                • Damage Control Patient Selection
                                                                                • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                • Questions
                                                                                • Summary and Conclusions

                                                                                  Blood Substitutes 2010

                                                                                  bull Ideal Red Cell Substitutendash Deliver oxygenndash No compatibility testingndash Few side effectsndash Prolonged storage capabilitiesndash Persist in the circulationndash Reasonable cost

                                                                                  bull Ready for prime time ndash not yet but soon - maybe

                                                                                  bull Cell-Free Hemoglobin-Based Blood Substitutes and Risk of Myocardial Infarction and Death

                                                                                  ndash JAMA - April 28 2008

                                                                                  Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                                  bull Direct pressure to all external bleeding

                                                                                  bull Rapid suturing of all scalp and facial wounds

                                                                                  bull Rapid application of ThomasHare Traction splints for femur fx

                                                                                  bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                                  dressings of mangled extremities

                                                                                  Pelvic Binders 2010

                                                                                  Optimizing ED Trauma Resuscitation (cont)

                                                                                  bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                                  Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                                  bull Use FAST to rapidly detect intra-abdominal fluid

                                                                                  bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                                  floor during chest tube insertion

                                                                                  Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                                  bull Intervene early in resuscitation to STOP bleeding

                                                                                  bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                                  interventionsbull Use novel methods to STOP bleeding in the

                                                                                  operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                                  coagulopathy

                                                                                  bull Controversialndash Whether to administer type and how much

                                                                                  bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                                  Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                                  MTP Process Shands at UF

                                                                                  Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                                  amp notifies designated RN

                                                                                  Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                                  refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                                  Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                                  runner to BB with cross amp match

                                                                                  MTP runner delivers blood products to designated RN

                                                                                  Ismore MTPneeded

                                                                                  EDOR ICU

                                                                                  Designated RN assures bloodadministered per MD order

                                                                                  Designated RN assures blood administered per MD order

                                                                                  Designated RN sends MTP runner for more blood

                                                                                  MTP site

                                                                                  Ispt to be

                                                                                  transported withblood

                                                                                  Designated RN transportsblood with pt to location(ORICU)

                                                                                  END

                                                                                  END

                                                                                  END

                                                                                  YES NO

                                                                                  YES

                                                                                  NO

                                                                                  ED = Nurse ScribeOR = Circ RN notifies

                                                                                  Charge Nurse

                                                                                  62406

                                                                                  ED Thoracotomy for Moribund Patients

                                                                                  bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                                  bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                                  bull Aortic cross-clamping

                                                                                  Optimizing Resuscitation Across the Continuum

                                                                                  bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                                  triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                                  bullbull RegroupRegroup

                                                                                  Damage Control Focus on Physiology

                                                                                  bull Major paradigm shift in operative management of devastating injuries

                                                                                  bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                  temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                  ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                  Damage Control Patient Selectionbull Instability

                                                                                  bull Hypothermia (lt 34deg C)

                                                                                  bull Coagulopathy

                                                                                  bull Acidosis (pHlt 72BD -8)

                                                                                  bull Major traumaAvoid ldquoground zero of damage control

                                                                                  (physiological decompensation)

                                                                                  Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                  bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                  bull Avoid hypotension in brain injured patients= poor outcome

                                                                                  bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                  bull Urgent CT and expert neurosurgical care is a must

                                                                                  Questions

                                                                                  Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                  Summary and Conclusionsbull It is truly all about the

                                                                                  patient

                                                                                  bull Team effort and framework is needed by design

                                                                                  bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                  bull Trauma centers save lives

                                                                                  • Welcome to Trauma Tracks
                                                                                  • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                  • OBJECTIVES
                                                                                  • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                  • Current Outcomes for CY 2009
                                                                                  • FRAMEWORK
                                                                                  • ProfileCredentials of a Trauma Patient
                                                                                  • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                  • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                  • Slide Number 10
                                                                                  • Slide Number 11
                                                                                  • Slide Number 12
                                                                                  • Slide Number 13
                                                                                  • Situation Awareness
                                                                                  • Most Potentially Preventable Trauma Deaths are related to
                                                                                  • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                  • Optimizing Resuscitation Across the Continuum
                                                                                  • Airway All trauma patients need oxygen until proven otherwise
                                                                                  • Airway All unstable trauma patients need a definitive airway
                                                                                  • Prehospital Intubation
                                                                                  • Prehospital Intubation
                                                                                  • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                  • Bridge Devices 2010
                                                                                  • Breathing All trauma patients need oxygen until proven otherwise
                                                                                  • CT Scan for thoracic trauma
                                                                                  • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                  • Hemorrhage PEARL
                                                                                  • Hemorrhage 5 Anatomic Areas of Origin
                                                                                  • Hemorrhage Importance of Lactate amp BD
                                                                                  • Persistent Acidosis Indicates
                                                                                  • Base Deficit Categories
                                                                                  • Uses of Base Deficit in Trauma Care
                                                                                  • Resuscitation End Points
                                                                                  • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                  • Goal Directed Therapy PEARL
                                                                                  • Optimizing Prehospital Resuscitation
                                                                                  • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                  • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                  • Tourniquets 2010
                                                                                  • Indications for Tourniquets
                                                                                  • Intraosseous Infusion Devices 2010
                                                                                  • Blood Substitutes 2010
                                                                                  • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                  • Pelvic Binders 2010
                                                                                  • Optimizing ED Trauma Resuscitation (cont)
                                                                                  • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                  • Slide Number 47
                                                                                  • Slide Number 48
                                                                                  • ED Thoracotomy for Moribund Patients
                                                                                  • Optimizing Resuscitation Across the Continuum
                                                                                  • Damage ControlFocus on Physiology
                                                                                  • Damage Control Patient Selection
                                                                                  • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                  • Questions
                                                                                  • Summary and Conclusions

                                                                                    Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR

                                                                                    bull Direct pressure to all external bleeding

                                                                                    bull Rapid suturing of all scalp and facial wounds

                                                                                    bull Rapid application of ThomasHare Traction splints for femur fx

                                                                                    bull Binder for pelvic fxbull Rapid reduction and pressure

                                                                                    dressings of mangled extremities

                                                                                    Pelvic Binders 2010

                                                                                    Optimizing ED Trauma Resuscitation (cont)

                                                                                    bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                                    Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                                    bull Use FAST to rapidly detect intra-abdominal fluid

                                                                                    bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                                    floor during chest tube insertion

                                                                                    Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                                    bull Intervene early in resuscitation to STOP bleeding

                                                                                    bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                                    interventionsbull Use novel methods to STOP bleeding in the

                                                                                    operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                                    coagulopathy

                                                                                    bull Controversialndash Whether to administer type and how much

                                                                                    bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                                    Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                                    MTP Process Shands at UF

                                                                                    Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                                    amp notifies designated RN

                                                                                    Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                                    refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                                    Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                                    runner to BB with cross amp match

                                                                                    MTP runner delivers blood products to designated RN

                                                                                    Ismore MTPneeded

                                                                                    EDOR ICU

                                                                                    Designated RN assures bloodadministered per MD order

                                                                                    Designated RN assures blood administered per MD order

                                                                                    Designated RN sends MTP runner for more blood

                                                                                    MTP site

                                                                                    Ispt to be

                                                                                    transported withblood

                                                                                    Designated RN transportsblood with pt to location(ORICU)

                                                                                    END

                                                                                    END

                                                                                    END

                                                                                    YES NO

                                                                                    YES

                                                                                    NO

                                                                                    ED = Nurse ScribeOR = Circ RN notifies

                                                                                    Charge Nurse

                                                                                    62406

                                                                                    ED Thoracotomy for Moribund Patients

                                                                                    bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                                    bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                                    bull Aortic cross-clamping

                                                                                    Optimizing Resuscitation Across the Continuum

                                                                                    bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                                    triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                                    bullbull RegroupRegroup

                                                                                    Damage Control Focus on Physiology

                                                                                    bull Major paradigm shift in operative management of devastating injuries

                                                                                    bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                    temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                    ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                    Damage Control Patient Selectionbull Instability

                                                                                    bull Hypothermia (lt 34deg C)

                                                                                    bull Coagulopathy

                                                                                    bull Acidosis (pHlt 72BD -8)

                                                                                    bull Major traumaAvoid ldquoground zero of damage control

                                                                                    (physiological decompensation)

                                                                                    Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                    bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                    bull Avoid hypotension in brain injured patients= poor outcome

                                                                                    bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                    bull Urgent CT and expert neurosurgical care is a must

                                                                                    Questions

                                                                                    Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                    Summary and Conclusionsbull It is truly all about the

                                                                                    patient

                                                                                    bull Team effort and framework is needed by design

                                                                                    bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                    bull Trauma centers save lives

                                                                                    • Welcome to Trauma Tracks
                                                                                    • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                    • OBJECTIVES
                                                                                    • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                    • Current Outcomes for CY 2009
                                                                                    • FRAMEWORK
                                                                                    • ProfileCredentials of a Trauma Patient
                                                                                    • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                    • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                    • Slide Number 10
                                                                                    • Slide Number 11
                                                                                    • Slide Number 12
                                                                                    • Slide Number 13
                                                                                    • Situation Awareness
                                                                                    • Most Potentially Preventable Trauma Deaths are related to
                                                                                    • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                    • Optimizing Resuscitation Across the Continuum
                                                                                    • Airway All trauma patients need oxygen until proven otherwise
                                                                                    • Airway All unstable trauma patients need a definitive airway
                                                                                    • Prehospital Intubation
                                                                                    • Prehospital Intubation
                                                                                    • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                    • Bridge Devices 2010
                                                                                    • Breathing All trauma patients need oxygen until proven otherwise
                                                                                    • CT Scan for thoracic trauma
                                                                                    • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                    • Hemorrhage PEARL
                                                                                    • Hemorrhage 5 Anatomic Areas of Origin
                                                                                    • Hemorrhage Importance of Lactate amp BD
                                                                                    • Persistent Acidosis Indicates
                                                                                    • Base Deficit Categories
                                                                                    • Uses of Base Deficit in Trauma Care
                                                                                    • Resuscitation End Points
                                                                                    • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                    • Goal Directed Therapy PEARL
                                                                                    • Optimizing Prehospital Resuscitation
                                                                                    • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                    • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                    • Tourniquets 2010
                                                                                    • Indications for Tourniquets
                                                                                    • Intraosseous Infusion Devices 2010
                                                                                    • Blood Substitutes 2010
                                                                                    • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                    • Pelvic Binders 2010
                                                                                    • Optimizing ED Trauma Resuscitation (cont)
                                                                                    • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                    • Slide Number 47
                                                                                    • Slide Number 48
                                                                                    • ED Thoracotomy for Moribund Patients
                                                                                    • Optimizing Resuscitation Across the Continuum
                                                                                    • Damage ControlFocus on Physiology
                                                                                    • Damage Control Patient Selection
                                                                                    • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                    • Questions
                                                                                    • Summary and Conclusions

                                                                                      Pelvic Binders 2010

                                                                                      Optimizing ED Trauma Resuscitation (cont)

                                                                                      bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                                      Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                                      bull Use FAST to rapidly detect intra-abdominal fluid

                                                                                      bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                                      floor during chest tube insertion

                                                                                      Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                                      bull Intervene early in resuscitation to STOP bleeding

                                                                                      bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                                      interventionsbull Use novel methods to STOP bleeding in the

                                                                                      operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                                      coagulopathy

                                                                                      bull Controversialndash Whether to administer type and how much

                                                                                      bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                                      Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                                      MTP Process Shands at UF

                                                                                      Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                                      amp notifies designated RN

                                                                                      Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                                      refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                                      Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                                      runner to BB with cross amp match

                                                                                      MTP runner delivers blood products to designated RN

                                                                                      Ismore MTPneeded

                                                                                      EDOR ICU

                                                                                      Designated RN assures bloodadministered per MD order

                                                                                      Designated RN assures blood administered per MD order

                                                                                      Designated RN sends MTP runner for more blood

                                                                                      MTP site

                                                                                      Ispt to be

                                                                                      transported withblood

                                                                                      Designated RN transportsblood with pt to location(ORICU)

                                                                                      END

                                                                                      END

                                                                                      END

                                                                                      YES NO

                                                                                      YES

                                                                                      NO

                                                                                      ED = Nurse ScribeOR = Circ RN notifies

                                                                                      Charge Nurse

                                                                                      62406

                                                                                      ED Thoracotomy for Moribund Patients

                                                                                      bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                                      bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                                      bull Aortic cross-clamping

                                                                                      Optimizing Resuscitation Across the Continuum

                                                                                      bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                                      triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                                      bullbull RegroupRegroup

                                                                                      Damage Control Focus on Physiology

                                                                                      bull Major paradigm shift in operative management of devastating injuries

                                                                                      bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                      temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                      ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                      Damage Control Patient Selectionbull Instability

                                                                                      bull Hypothermia (lt 34deg C)

                                                                                      bull Coagulopathy

                                                                                      bull Acidosis (pHlt 72BD -8)

                                                                                      bull Major traumaAvoid ldquoground zero of damage control

                                                                                      (physiological decompensation)

                                                                                      Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                      bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                      bull Avoid hypotension in brain injured patients= poor outcome

                                                                                      bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                      bull Urgent CT and expert neurosurgical care is a must

                                                                                      Questions

                                                                                      Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                      Summary and Conclusionsbull It is truly all about the

                                                                                      patient

                                                                                      bull Team effort and framework is needed by design

                                                                                      bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                      bull Trauma centers save lives

                                                                                      • Welcome to Trauma Tracks
                                                                                      • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                      • OBJECTIVES
                                                                                      • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                      • Current Outcomes for CY 2009
                                                                                      • FRAMEWORK
                                                                                      • ProfileCredentials of a Trauma Patient
                                                                                      • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                      • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                      • Slide Number 10
                                                                                      • Slide Number 11
                                                                                      • Slide Number 12
                                                                                      • Slide Number 13
                                                                                      • Situation Awareness
                                                                                      • Most Potentially Preventable Trauma Deaths are related to
                                                                                      • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                      • Optimizing Resuscitation Across the Continuum
                                                                                      • Airway All trauma patients need oxygen until proven otherwise
                                                                                      • Airway All unstable trauma patients need a definitive airway
                                                                                      • Prehospital Intubation
                                                                                      • Prehospital Intubation
                                                                                      • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                      • Bridge Devices 2010
                                                                                      • Breathing All trauma patients need oxygen until proven otherwise
                                                                                      • CT Scan for thoracic trauma
                                                                                      • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                      • Hemorrhage PEARL
                                                                                      • Hemorrhage 5 Anatomic Areas of Origin
                                                                                      • Hemorrhage Importance of Lactate amp BD
                                                                                      • Persistent Acidosis Indicates
                                                                                      • Base Deficit Categories
                                                                                      • Uses of Base Deficit in Trauma Care
                                                                                      • Resuscitation End Points
                                                                                      • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                      • Goal Directed Therapy PEARL
                                                                                      • Optimizing Prehospital Resuscitation
                                                                                      • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                      • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                      • Tourniquets 2010
                                                                                      • Indications for Tourniquets
                                                                                      • Intraosseous Infusion Devices 2010
                                                                                      • Blood Substitutes 2010
                                                                                      • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                      • Pelvic Binders 2010
                                                                                      • Optimizing ED Trauma Resuscitation (cont)
                                                                                      • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                      • Slide Number 47
                                                                                      • Slide Number 48
                                                                                      • ED Thoracotomy for Moribund Patients
                                                                                      • Optimizing Resuscitation Across the Continuum
                                                                                      • Damage ControlFocus on Physiology
                                                                                      • Damage Control Patient Selection
                                                                                      • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                      • Questions
                                                                                      • Summary and Conclusions

                                                                                        Optimizing ED Trauma Resuscitation (cont)

                                                                                        bull Low volume blood sampling ndash 3 cc for ISTAT NaKClCa Hgb

                                                                                        Hct PO2 PCO2 pH PT INR Lactic acid Creatinine Troponin

                                                                                        bull Use FAST to rapidly detect intra-abdominal fluid

                                                                                        bull Auto transfusion of thoracic blood using the pleurevac systemndash Avoid spilling blood on

                                                                                        floor during chest tube insertion

                                                                                        Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                                        bull Intervene early in resuscitation to STOP bleeding

                                                                                        bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                                        interventionsbull Use novel methods to STOP bleeding in the

                                                                                        operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                                        coagulopathy

                                                                                        bull Controversialndash Whether to administer type and how much

                                                                                        bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                                        Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                                        MTP Process Shands at UF

                                                                                        Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                                        amp notifies designated RN

                                                                                        Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                                        refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                                        Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                                        runner to BB with cross amp match

                                                                                        MTP runner delivers blood products to designated RN

                                                                                        Ismore MTPneeded

                                                                                        EDOR ICU

                                                                                        Designated RN assures bloodadministered per MD order

                                                                                        Designated RN assures blood administered per MD order

                                                                                        Designated RN sends MTP runner for more blood

                                                                                        MTP site

                                                                                        Ispt to be

                                                                                        transported withblood

                                                                                        Designated RN transportsblood with pt to location(ORICU)

                                                                                        END

                                                                                        END

                                                                                        END

                                                                                        YES NO

                                                                                        YES

                                                                                        NO

                                                                                        ED = Nurse ScribeOR = Circ RN notifies

                                                                                        Charge Nurse

                                                                                        62406

                                                                                        ED Thoracotomy for Moribund Patients

                                                                                        bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                                        bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                                        bull Aortic cross-clamping

                                                                                        Optimizing Resuscitation Across the Continuum

                                                                                        bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                                        triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                                        bullbull RegroupRegroup

                                                                                        Damage Control Focus on Physiology

                                                                                        bull Major paradigm shift in operative management of devastating injuries

                                                                                        bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                        temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                        ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                        Damage Control Patient Selectionbull Instability

                                                                                        bull Hypothermia (lt 34deg C)

                                                                                        bull Coagulopathy

                                                                                        bull Acidosis (pHlt 72BD -8)

                                                                                        bull Major traumaAvoid ldquoground zero of damage control

                                                                                        (physiological decompensation)

                                                                                        Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                        bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                        bull Avoid hypotension in brain injured patients= poor outcome

                                                                                        bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                        bull Urgent CT and expert neurosurgical care is a must

                                                                                        Questions

                                                                                        Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                        Summary and Conclusionsbull It is truly all about the

                                                                                        patient

                                                                                        bull Team effort and framework is needed by design

                                                                                        bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                        bull Trauma centers save lives

                                                                                        • Welcome to Trauma Tracks
                                                                                        • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                        • OBJECTIVES
                                                                                        • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                        • Current Outcomes for CY 2009
                                                                                        • FRAMEWORK
                                                                                        • ProfileCredentials of a Trauma Patient
                                                                                        • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                        • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                        • Slide Number 10
                                                                                        • Slide Number 11
                                                                                        • Slide Number 12
                                                                                        • Slide Number 13
                                                                                        • Situation Awareness
                                                                                        • Most Potentially Preventable Trauma Deaths are related to
                                                                                        • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                        • Optimizing Resuscitation Across the Continuum
                                                                                        • Airway All trauma patients need oxygen until proven otherwise
                                                                                        • Airway All unstable trauma patients need a definitive airway
                                                                                        • Prehospital Intubation
                                                                                        • Prehospital Intubation
                                                                                        • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                        • Bridge Devices 2010
                                                                                        • Breathing All trauma patients need oxygen until proven otherwise
                                                                                        • CT Scan for thoracic trauma
                                                                                        • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                        • Hemorrhage PEARL
                                                                                        • Hemorrhage 5 Anatomic Areas of Origin
                                                                                        • Hemorrhage Importance of Lactate amp BD
                                                                                        • Persistent Acidosis Indicates
                                                                                        • Base Deficit Categories
                                                                                        • Uses of Base Deficit in Trauma Care
                                                                                        • Resuscitation End Points
                                                                                        • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                        • Goal Directed Therapy PEARL
                                                                                        • Optimizing Prehospital Resuscitation
                                                                                        • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                        • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                        • Tourniquets 2010
                                                                                        • Indications for Tourniquets
                                                                                        • Intraosseous Infusion Devices 2010
                                                                                        • Blood Substitutes 2010
                                                                                        • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                        • Pelvic Binders 2010
                                                                                        • Optimizing ED Trauma Resuscitation (cont)
                                                                                        • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                        • Slide Number 47
                                                                                        • Slide Number 48
                                                                                        • ED Thoracotomy for Moribund Patients
                                                                                        • Optimizing Resuscitation Across the Continuum
                                                                                        • Damage ControlFocus on Physiology
                                                                                        • Damage Control Patient Selection
                                                                                        • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                        • Questions
                                                                                        • Summary and Conclusions

                                                                                          Optimizing ResuscitationOptimizing Resuscitation-- Interventions to Decrease the Need for Blood Transfusion

                                                                                          bull Intervene early in resuscitation to STOP bleeding

                                                                                          bull Conserve blood earlybull Aggressive rapid and efficient operative

                                                                                          interventionsbull Use novel methods to STOP bleeding in the

                                                                                          operating theaterbull Early use of interventional radiologybull Correct hypothermia acidosis

                                                                                          coagulopathy

                                                                                          bull Controversialndash Whether to administer type and how much

                                                                                          bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                                          Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                                          MTP Process Shands at UF

                                                                                          Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                                          amp notifies designated RN

                                                                                          Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                                          refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                                          Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                                          runner to BB with cross amp match

                                                                                          MTP runner delivers blood products to designated RN

                                                                                          Ismore MTPneeded

                                                                                          EDOR ICU

                                                                                          Designated RN assures bloodadministered per MD order

                                                                                          Designated RN assures blood administered per MD order

                                                                                          Designated RN sends MTP runner for more blood

                                                                                          MTP site

                                                                                          Ispt to be

                                                                                          transported withblood

                                                                                          Designated RN transportsblood with pt to location(ORICU)

                                                                                          END

                                                                                          END

                                                                                          END

                                                                                          YES NO

                                                                                          YES

                                                                                          NO

                                                                                          ED = Nurse ScribeOR = Circ RN notifies

                                                                                          Charge Nurse

                                                                                          62406

                                                                                          ED Thoracotomy for Moribund Patients

                                                                                          bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                                          bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                                          bull Aortic cross-clamping

                                                                                          Optimizing Resuscitation Across the Continuum

                                                                                          bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                                          triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                                          bullbull RegroupRegroup

                                                                                          Damage Control Focus on Physiology

                                                                                          bull Major paradigm shift in operative management of devastating injuries

                                                                                          bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                          temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                          ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                          Damage Control Patient Selectionbull Instability

                                                                                          bull Hypothermia (lt 34deg C)

                                                                                          bull Coagulopathy

                                                                                          bull Acidosis (pHlt 72BD -8)

                                                                                          bull Major traumaAvoid ldquoground zero of damage control

                                                                                          (physiological decompensation)

                                                                                          Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                          bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                          bull Avoid hypotension in brain injured patients= poor outcome

                                                                                          bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                          bull Urgent CT and expert neurosurgical care is a must

                                                                                          Questions

                                                                                          Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                          Summary and Conclusionsbull It is truly all about the

                                                                                          patient

                                                                                          bull Team effort and framework is needed by design

                                                                                          bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                          bull Trauma centers save lives

                                                                                          • Welcome to Trauma Tracks
                                                                                          • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                          • OBJECTIVES
                                                                                          • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                          • Current Outcomes for CY 2009
                                                                                          • FRAMEWORK
                                                                                          • ProfileCredentials of a Trauma Patient
                                                                                          • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                          • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                          • Slide Number 10
                                                                                          • Slide Number 11
                                                                                          • Slide Number 12
                                                                                          • Slide Number 13
                                                                                          • Situation Awareness
                                                                                          • Most Potentially Preventable Trauma Deaths are related to
                                                                                          • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                          • Optimizing Resuscitation Across the Continuum
                                                                                          • Airway All trauma patients need oxygen until proven otherwise
                                                                                          • Airway All unstable trauma patients need a definitive airway
                                                                                          • Prehospital Intubation
                                                                                          • Prehospital Intubation
                                                                                          • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                          • Bridge Devices 2010
                                                                                          • Breathing All trauma patients need oxygen until proven otherwise
                                                                                          • CT Scan for thoracic trauma
                                                                                          • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                          • Hemorrhage PEARL
                                                                                          • Hemorrhage 5 Anatomic Areas of Origin
                                                                                          • Hemorrhage Importance of Lactate amp BD
                                                                                          • Persistent Acidosis Indicates
                                                                                          • Base Deficit Categories
                                                                                          • Uses of Base Deficit in Trauma Care
                                                                                          • Resuscitation End Points
                                                                                          • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                          • Goal Directed Therapy PEARL
                                                                                          • Optimizing Prehospital Resuscitation
                                                                                          • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                          • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                          • Tourniquets 2010
                                                                                          • Indications for Tourniquets
                                                                                          • Intraosseous Infusion Devices 2010
                                                                                          • Blood Substitutes 2010
                                                                                          • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                          • Pelvic Binders 2010
                                                                                          • Optimizing ED Trauma Resuscitation (cont)
                                                                                          • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                          • Slide Number 47
                                                                                          • Slide Number 48
                                                                                          • ED Thoracotomy for Moribund Patients
                                                                                          • Optimizing Resuscitation Across the Continuum
                                                                                          • Damage ControlFocus on Physiology
                                                                                          • Damage Control Patient Selection
                                                                                          • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                          • Questions
                                                                                          • Summary and Conclusions

                                                                                            bull Controversialndash Whether to administer type and how much

                                                                                            bull Must maintain a critical level of perfusion to vital organs while avoiding over-resuscitationndash reverses vasoconstriction of injured vesselsndash dislodges early clotndash dilutes coagulation factorsndash cools the patientndash induces visceral swelling

                                                                                            Optimizing ED Trauma Resuscitation- Fluid Resuscitation

                                                                                            MTP Process Shands at UF

                                                                                            Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                                            amp notifies designated RN

                                                                                            Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                                            refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                                            Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                                            runner to BB with cross amp match

                                                                                            MTP runner delivers blood products to designated RN

                                                                                            Ismore MTPneeded

                                                                                            EDOR ICU

                                                                                            Designated RN assures bloodadministered per MD order

                                                                                            Designated RN assures blood administered per MD order

                                                                                            Designated RN sends MTP runner for more blood

                                                                                            MTP site

                                                                                            Ispt to be

                                                                                            transported withblood

                                                                                            Designated RN transportsblood with pt to location(ORICU)

                                                                                            END

                                                                                            END

                                                                                            END

                                                                                            YES NO

                                                                                            YES

                                                                                            NO

                                                                                            ED = Nurse ScribeOR = Circ RN notifies

                                                                                            Charge Nurse

                                                                                            62406

                                                                                            ED Thoracotomy for Moribund Patients

                                                                                            bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                                            bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                                            bull Aortic cross-clamping

                                                                                            Optimizing Resuscitation Across the Continuum

                                                                                            bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                                            triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                                            bullbull RegroupRegroup

                                                                                            Damage Control Focus on Physiology

                                                                                            bull Major paradigm shift in operative management of devastating injuries

                                                                                            bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                            temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                            ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                            Damage Control Patient Selectionbull Instability

                                                                                            bull Hypothermia (lt 34deg C)

                                                                                            bull Coagulopathy

                                                                                            bull Acidosis (pHlt 72BD -8)

                                                                                            bull Major traumaAvoid ldquoground zero of damage control

                                                                                            (physiological decompensation)

                                                                                            Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                            bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                            bull Avoid hypotension in brain injured patients= poor outcome

                                                                                            bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                            bull Urgent CT and expert neurosurgical care is a must

                                                                                            Questions

                                                                                            Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                            Summary and Conclusionsbull It is truly all about the

                                                                                            patient

                                                                                            bull Team effort and framework is needed by design

                                                                                            bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                            bull Trauma centers save lives

                                                                                            • Welcome to Trauma Tracks
                                                                                            • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                            • OBJECTIVES
                                                                                            • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                            • Current Outcomes for CY 2009
                                                                                            • FRAMEWORK
                                                                                            • ProfileCredentials of a Trauma Patient
                                                                                            • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                            • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                            • Slide Number 10
                                                                                            • Slide Number 11
                                                                                            • Slide Number 12
                                                                                            • Slide Number 13
                                                                                            • Situation Awareness
                                                                                            • Most Potentially Preventable Trauma Deaths are related to
                                                                                            • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                            • Optimizing Resuscitation Across the Continuum
                                                                                            • Airway All trauma patients need oxygen until proven otherwise
                                                                                            • Airway All unstable trauma patients need a definitive airway
                                                                                            • Prehospital Intubation
                                                                                            • Prehospital Intubation
                                                                                            • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                            • Bridge Devices 2010
                                                                                            • Breathing All trauma patients need oxygen until proven otherwise
                                                                                            • CT Scan for thoracic trauma
                                                                                            • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                            • Hemorrhage PEARL
                                                                                            • Hemorrhage 5 Anatomic Areas of Origin
                                                                                            • Hemorrhage Importance of Lactate amp BD
                                                                                            • Persistent Acidosis Indicates
                                                                                            • Base Deficit Categories
                                                                                            • Uses of Base Deficit in Trauma Care
                                                                                            • Resuscitation End Points
                                                                                            • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                            • Goal Directed Therapy PEARL
                                                                                            • Optimizing Prehospital Resuscitation
                                                                                            • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                            • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                            • Tourniquets 2010
                                                                                            • Indications for Tourniquets
                                                                                            • Intraosseous Infusion Devices 2010
                                                                                            • Blood Substitutes 2010
                                                                                            • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                            • Pelvic Binders 2010
                                                                                            • Optimizing ED Trauma Resuscitation (cont)
                                                                                            • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                            • Slide Number 47
                                                                                            • Slide Number 48
                                                                                            • ED Thoracotomy for Moribund Patients
                                                                                            • Optimizing Resuscitation Across the Continuum
                                                                                            • Damage ControlFocus on Physiology
                                                                                            • Damage Control Patient Selection
                                                                                            • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                            • Questions
                                                                                            • Summary and Conclusions

                                                                                              MTP Process Shands at UF

                                                                                              Attending Fellow Chief ResidentActing Chief Resident initiates MTP

                                                                                              amp notifies designated RN

                                                                                              Designated RNbull Calls BB to unlock refrigeratorbull Logs out blood from MTP

                                                                                              refrigerator amp deliversbull Sends designated MTP Runner to BB with cross amp match

                                                                                              Designate RN (ICU Charge Nurse)bull Calls BB with MTP alertbull Sends designated MTP

                                                                                              runner to BB with cross amp match

                                                                                              MTP runner delivers blood products to designated RN

                                                                                              Ismore MTPneeded

                                                                                              EDOR ICU

                                                                                              Designated RN assures bloodadministered per MD order

                                                                                              Designated RN assures blood administered per MD order

                                                                                              Designated RN sends MTP runner for more blood

                                                                                              MTP site

                                                                                              Ispt to be

                                                                                              transported withblood

                                                                                              Designated RN transportsblood with pt to location(ORICU)

                                                                                              END

                                                                                              END

                                                                                              END

                                                                                              YES NO

                                                                                              YES

                                                                                              NO

                                                                                              ED = Nurse ScribeOR = Circ RN notifies

                                                                                              Charge Nurse

                                                                                              62406

                                                                                              ED Thoracotomy for Moribund Patients

                                                                                              bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                                              bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                                              bull Aortic cross-clamping

                                                                                              Optimizing Resuscitation Across the Continuum

                                                                                              bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                                              triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                                              bullbull RegroupRegroup

                                                                                              Damage Control Focus on Physiology

                                                                                              bull Major paradigm shift in operative management of devastating injuries

                                                                                              bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                              temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                              ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                              Damage Control Patient Selectionbull Instability

                                                                                              bull Hypothermia (lt 34deg C)

                                                                                              bull Coagulopathy

                                                                                              bull Acidosis (pHlt 72BD -8)

                                                                                              bull Major traumaAvoid ldquoground zero of damage control

                                                                                              (physiological decompensation)

                                                                                              Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                              bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                              bull Avoid hypotension in brain injured patients= poor outcome

                                                                                              bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                              bull Urgent CT and expert neurosurgical care is a must

                                                                                              Questions

                                                                                              Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                              Summary and Conclusionsbull It is truly all about the

                                                                                              patient

                                                                                              bull Team effort and framework is needed by design

                                                                                              bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                              bull Trauma centers save lives

                                                                                              • Welcome to Trauma Tracks
                                                                                              • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                              • OBJECTIVES
                                                                                              • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                              • Current Outcomes for CY 2009
                                                                                              • FRAMEWORK
                                                                                              • ProfileCredentials of a Trauma Patient
                                                                                              • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                              • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                              • Slide Number 10
                                                                                              • Slide Number 11
                                                                                              • Slide Number 12
                                                                                              • Slide Number 13
                                                                                              • Situation Awareness
                                                                                              • Most Potentially Preventable Trauma Deaths are related to
                                                                                              • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                              • Optimizing Resuscitation Across the Continuum
                                                                                              • Airway All trauma patients need oxygen until proven otherwise
                                                                                              • Airway All unstable trauma patients need a definitive airway
                                                                                              • Prehospital Intubation
                                                                                              • Prehospital Intubation
                                                                                              • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                              • Bridge Devices 2010
                                                                                              • Breathing All trauma patients need oxygen until proven otherwise
                                                                                              • CT Scan for thoracic trauma
                                                                                              • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                              • Hemorrhage PEARL
                                                                                              • Hemorrhage 5 Anatomic Areas of Origin
                                                                                              • Hemorrhage Importance of Lactate amp BD
                                                                                              • Persistent Acidosis Indicates
                                                                                              • Base Deficit Categories
                                                                                              • Uses of Base Deficit in Trauma Care
                                                                                              • Resuscitation End Points
                                                                                              • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                              • Goal Directed Therapy PEARL
                                                                                              • Optimizing Prehospital Resuscitation
                                                                                              • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                              • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                              • Tourniquets 2010
                                                                                              • Indications for Tourniquets
                                                                                              • Intraosseous Infusion Devices 2010
                                                                                              • Blood Substitutes 2010
                                                                                              • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                              • Pelvic Binders 2010
                                                                                              • Optimizing ED Trauma Resuscitation (cont)
                                                                                              • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                              • Slide Number 47
                                                                                              • Slide Number 48
                                                                                              • ED Thoracotomy for Moribund Patients
                                                                                              • Optimizing Resuscitation Across the Continuum
                                                                                              • Damage ControlFocus on Physiology
                                                                                              • Damage Control Patient Selection
                                                                                              • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                              • Questions
                                                                                              • Summary and Conclusions

                                                                                                ED Thoracotomy for Moribund Patients

                                                                                                bull Cases of Blunt Chest or Abdominal Trauma 5-year study by Fialka C et al (2004) Journal of Trauma

                                                                                                bull Patients with blunt trunk trauma amp cardiac arrest with severe hemorrhagic shock may benefit from open-chest CPR with same probability as shown with penetrating injuries

                                                                                                bull Aortic cross-clamping

                                                                                                Optimizing Resuscitation Across the Continuum

                                                                                                bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                                                triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                                                bullbull RegroupRegroup

                                                                                                Damage Control Focus on Physiology

                                                                                                bull Major paradigm shift in operative management of devastating injuries

                                                                                                bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                                temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                                ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                                Damage Control Patient Selectionbull Instability

                                                                                                bull Hypothermia (lt 34deg C)

                                                                                                bull Coagulopathy

                                                                                                bull Acidosis (pHlt 72BD -8)

                                                                                                bull Major traumaAvoid ldquoground zero of damage control

                                                                                                (physiological decompensation)

                                                                                                Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                                bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                                bull Avoid hypotension in brain injured patients= poor outcome

                                                                                                bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                                bull Urgent CT and expert neurosurgical care is a must

                                                                                                Questions

                                                                                                Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                                Summary and Conclusionsbull It is truly all about the

                                                                                                patient

                                                                                                bull Team effort and framework is needed by design

                                                                                                bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                                bull Trauma centers save lives

                                                                                                • Welcome to Trauma Tracks
                                                                                                • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                                • OBJECTIVES
                                                                                                • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                                • Current Outcomes for CY 2009
                                                                                                • FRAMEWORK
                                                                                                • ProfileCredentials of a Trauma Patient
                                                                                                • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                                • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                                • Slide Number 10
                                                                                                • Slide Number 11
                                                                                                • Slide Number 12
                                                                                                • Slide Number 13
                                                                                                • Situation Awareness
                                                                                                • Most Potentially Preventable Trauma Deaths are related to
                                                                                                • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                                • Optimizing Resuscitation Across the Continuum
                                                                                                • Airway All trauma patients need oxygen until proven otherwise
                                                                                                • Airway All unstable trauma patients need a definitive airway
                                                                                                • Prehospital Intubation
                                                                                                • Prehospital Intubation
                                                                                                • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                                • Bridge Devices 2010
                                                                                                • Breathing All trauma patients need oxygen until proven otherwise
                                                                                                • CT Scan for thoracic trauma
                                                                                                • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                                • Hemorrhage PEARL
                                                                                                • Hemorrhage 5 Anatomic Areas of Origin
                                                                                                • Hemorrhage Importance of Lactate amp BD
                                                                                                • Persistent Acidosis Indicates
                                                                                                • Base Deficit Categories
                                                                                                • Uses of Base Deficit in Trauma Care
                                                                                                • Resuscitation End Points
                                                                                                • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                                • Goal Directed Therapy PEARL
                                                                                                • Optimizing Prehospital Resuscitation
                                                                                                • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                                • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                                • Tourniquets 2010
                                                                                                • Indications for Tourniquets
                                                                                                • Intraosseous Infusion Devices 2010
                                                                                                • Blood Substitutes 2010
                                                                                                • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                                • Pelvic Binders 2010
                                                                                                • Optimizing ED Trauma Resuscitation (cont)
                                                                                                • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                                • Slide Number 47
                                                                                                • Slide Number 48
                                                                                                • ED Thoracotomy for Moribund Patients
                                                                                                • Optimizing Resuscitation Across the Continuum
                                                                                                • Damage ControlFocus on Physiology
                                                                                                • Damage Control Patient Selection
                                                                                                • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                                • Questions
                                                                                                • Summary and Conclusions

                                                                                                  Optimizing Resuscitation Across the Continuum

                                                                                                  bullbull Operating RoomOperating Roomndashndash Rapid exposureRapid exposurendashndash Evacuation of bloodEvacuation of bloodndashndash PackingPackingndashndash Control contaminationControl contaminationndashndash Anticipate and fight the Anticipate and fight the

                                                                                                  triadtriadrdquordquo of death of death Hypothermia Acidosis Hypothermia Acidosis CoagulopathyCoagulopathy

                                                                                                  bullbull RegroupRegroup

                                                                                                  Damage Control Focus on Physiology

                                                                                                  bull Major paradigm shift in operative management of devastating injuries

                                                                                                  bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                                  temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                                  ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                                  Damage Control Patient Selectionbull Instability

                                                                                                  bull Hypothermia (lt 34deg C)

                                                                                                  bull Coagulopathy

                                                                                                  bull Acidosis (pHlt 72BD -8)

                                                                                                  bull Major traumaAvoid ldquoground zero of damage control

                                                                                                  (physiological decompensation)

                                                                                                  Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                                  bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                                  bull Avoid hypotension in brain injured patients= poor outcome

                                                                                                  bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                                  bull Urgent CT and expert neurosurgical care is a must

                                                                                                  Questions

                                                                                                  Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                                  Summary and Conclusionsbull It is truly all about the

                                                                                                  patient

                                                                                                  bull Team effort and framework is needed by design

                                                                                                  bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                                  bull Trauma centers save lives

                                                                                                  • Welcome to Trauma Tracks
                                                                                                  • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                                  • OBJECTIVES
                                                                                                  • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                                  • Current Outcomes for CY 2009
                                                                                                  • FRAMEWORK
                                                                                                  • ProfileCredentials of a Trauma Patient
                                                                                                  • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                                  • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                                  • Slide Number 10
                                                                                                  • Slide Number 11
                                                                                                  • Slide Number 12
                                                                                                  • Slide Number 13
                                                                                                  • Situation Awareness
                                                                                                  • Most Potentially Preventable Trauma Deaths are related to
                                                                                                  • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                                  • Optimizing Resuscitation Across the Continuum
                                                                                                  • Airway All trauma patients need oxygen until proven otherwise
                                                                                                  • Airway All unstable trauma patients need a definitive airway
                                                                                                  • Prehospital Intubation
                                                                                                  • Prehospital Intubation
                                                                                                  • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                                  • Bridge Devices 2010
                                                                                                  • Breathing All trauma patients need oxygen until proven otherwise
                                                                                                  • CT Scan for thoracic trauma
                                                                                                  • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                                  • Hemorrhage PEARL
                                                                                                  • Hemorrhage 5 Anatomic Areas of Origin
                                                                                                  • Hemorrhage Importance of Lactate amp BD
                                                                                                  • Persistent Acidosis Indicates
                                                                                                  • Base Deficit Categories
                                                                                                  • Uses of Base Deficit in Trauma Care
                                                                                                  • Resuscitation End Points
                                                                                                  • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                                  • Goal Directed Therapy PEARL
                                                                                                  • Optimizing Prehospital Resuscitation
                                                                                                  • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                                  • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                                  • Tourniquets 2010
                                                                                                  • Indications for Tourniquets
                                                                                                  • Intraosseous Infusion Devices 2010
                                                                                                  • Blood Substitutes 2010
                                                                                                  • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                                  • Pelvic Binders 2010
                                                                                                  • Optimizing ED Trauma Resuscitation (cont)
                                                                                                  • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                                  • Slide Number 47
                                                                                                  • Slide Number 48
                                                                                                  • ED Thoracotomy for Moribund Patients
                                                                                                  • Optimizing Resuscitation Across the Continuum
                                                                                                  • Damage ControlFocus on Physiology
                                                                                                  • Damage Control Patient Selection
                                                                                                  • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                                  • Questions
                                                                                                  • Summary and Conclusions

                                                                                                    Damage Control Focus on Physiology

                                                                                                    bull Major paradigm shift in operative management of devastating injuries

                                                                                                    bull Abbreviated laparotomy and planned reoperationbull Bleeding and intestinal contamination are

                                                                                                    temporarily controlled by packing ligating stapling amp temporary vascular shunts amp abdominal cavity is closed rapidly

                                                                                                    ((Rotondo et al 1993 Shapiro et al 2000 Rotondo et al 1993 Shapiro et al 2000 Johnson et al 2001 Johnson et al 2001 J TraumaJ Trauma))

                                                                                                    Damage Control Patient Selectionbull Instability

                                                                                                    bull Hypothermia (lt 34deg C)

                                                                                                    bull Coagulopathy

                                                                                                    bull Acidosis (pHlt 72BD -8)

                                                                                                    bull Major traumaAvoid ldquoground zero of damage control

                                                                                                    (physiological decompensation)

                                                                                                    Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                                    bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                                    bull Avoid hypotension in brain injured patients= poor outcome

                                                                                                    bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                                    bull Urgent CT and expert neurosurgical care is a must

                                                                                                    Questions

                                                                                                    Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                                    Summary and Conclusionsbull It is truly all about the

                                                                                                    patient

                                                                                                    bull Team effort and framework is needed by design

                                                                                                    bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                                    bull Trauma centers save lives

                                                                                                    • Welcome to Trauma Tracks
                                                                                                    • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                                    • OBJECTIVES
                                                                                                    • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                                    • Current Outcomes for CY 2009
                                                                                                    • FRAMEWORK
                                                                                                    • ProfileCredentials of a Trauma Patient
                                                                                                    • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                                    • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                                    • Slide Number 10
                                                                                                    • Slide Number 11
                                                                                                    • Slide Number 12
                                                                                                    • Slide Number 13
                                                                                                    • Situation Awareness
                                                                                                    • Most Potentially Preventable Trauma Deaths are related to
                                                                                                    • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                                    • Optimizing Resuscitation Across the Continuum
                                                                                                    • Airway All trauma patients need oxygen until proven otherwise
                                                                                                    • Airway All unstable trauma patients need a definitive airway
                                                                                                    • Prehospital Intubation
                                                                                                    • Prehospital Intubation
                                                                                                    • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                                    • Bridge Devices 2010
                                                                                                    • Breathing All trauma patients need oxygen until proven otherwise
                                                                                                    • CT Scan for thoracic trauma
                                                                                                    • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                                    • Hemorrhage PEARL
                                                                                                    • Hemorrhage 5 Anatomic Areas of Origin
                                                                                                    • Hemorrhage Importance of Lactate amp BD
                                                                                                    • Persistent Acidosis Indicates
                                                                                                    • Base Deficit Categories
                                                                                                    • Uses of Base Deficit in Trauma Care
                                                                                                    • Resuscitation End Points
                                                                                                    • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                                    • Goal Directed Therapy PEARL
                                                                                                    • Optimizing Prehospital Resuscitation
                                                                                                    • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                                    • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                                    • Tourniquets 2010
                                                                                                    • Indications for Tourniquets
                                                                                                    • Intraosseous Infusion Devices 2010
                                                                                                    • Blood Substitutes 2010
                                                                                                    • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                                    • Pelvic Binders 2010
                                                                                                    • Optimizing ED Trauma Resuscitation (cont)
                                                                                                    • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                                    • Slide Number 47
                                                                                                    • Slide Number 48
                                                                                                    • ED Thoracotomy for Moribund Patients
                                                                                                    • Optimizing Resuscitation Across the Continuum
                                                                                                    • Damage ControlFocus on Physiology
                                                                                                    • Damage Control Patient Selection
                                                                                                    • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                                    • Questions
                                                                                                    • Summary and Conclusions

                                                                                                      Damage Control Patient Selectionbull Instability

                                                                                                      bull Hypothermia (lt 34deg C)

                                                                                                      bull Coagulopathy

                                                                                                      bull Acidosis (pHlt 72BD -8)

                                                                                                      bull Major traumaAvoid ldquoground zero of damage control

                                                                                                      (physiological decompensation)

                                                                                                      Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                                      bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                                      bull Avoid hypotension in brain injured patients= poor outcome

                                                                                                      bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                                      bull Urgent CT and expert neurosurgical care is a must

                                                                                                      Questions

                                                                                                      Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                                      Summary and Conclusionsbull It is truly all about the

                                                                                                      patient

                                                                                                      bull Team effort and framework is needed by design

                                                                                                      bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                                      bull Trauma centers save lives

                                                                                                      • Welcome to Trauma Tracks
                                                                                                      • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                                      • OBJECTIVES
                                                                                                      • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                                      • Current Outcomes for CY 2009
                                                                                                      • FRAMEWORK
                                                                                                      • ProfileCredentials of a Trauma Patient
                                                                                                      • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                                      • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                                      • Slide Number 10
                                                                                                      • Slide Number 11
                                                                                                      • Slide Number 12
                                                                                                      • Slide Number 13
                                                                                                      • Situation Awareness
                                                                                                      • Most Potentially Preventable Trauma Deaths are related to
                                                                                                      • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                                      • Optimizing Resuscitation Across the Continuum
                                                                                                      • Airway All trauma patients need oxygen until proven otherwise
                                                                                                      • Airway All unstable trauma patients need a definitive airway
                                                                                                      • Prehospital Intubation
                                                                                                      • Prehospital Intubation
                                                                                                      • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                                      • Bridge Devices 2010
                                                                                                      • Breathing All trauma patients need oxygen until proven otherwise
                                                                                                      • CT Scan for thoracic trauma
                                                                                                      • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                                      • Hemorrhage PEARL
                                                                                                      • Hemorrhage 5 Anatomic Areas of Origin
                                                                                                      • Hemorrhage Importance of Lactate amp BD
                                                                                                      • Persistent Acidosis Indicates
                                                                                                      • Base Deficit Categories
                                                                                                      • Uses of Base Deficit in Trauma Care
                                                                                                      • Resuscitation End Points
                                                                                                      • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                                      • Goal Directed Therapy PEARL
                                                                                                      • Optimizing Prehospital Resuscitation
                                                                                                      • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                                      • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                                      • Tourniquets 2010
                                                                                                      • Indications for Tourniquets
                                                                                                      • Intraosseous Infusion Devices 2010
                                                                                                      • Blood Substitutes 2010
                                                                                                      • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                                      • Pelvic Binders 2010
                                                                                                      • Optimizing ED Trauma Resuscitation (cont)
                                                                                                      • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                                      • Slide Number 47
                                                                                                      • Slide Number 48
                                                                                                      • ED Thoracotomy for Moribund Patients
                                                                                                      • Optimizing Resuscitation Across the Continuum
                                                                                                      • Damage ControlFocus on Physiology
                                                                                                      • Damage Control Patient Selection
                                                                                                      • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                                      • Questions
                                                                                                      • Summary and Conclusions

                                                                                                        Neurological All unconscious trauma patients have brain injury until proven otherwise

                                                                                                        bull Expanding intracranial hemorrhage requires optimization of oxygenation ventilation and circulatory support

                                                                                                        bull Avoid hypotension in brain injured patients= poor outcome

                                                                                                        bull Double jeopardy in unstable patients with severe head injury Associated brain injuries are present in up to 60 of patients with severe blunt trauma

                                                                                                        bull Urgent CT and expert neurosurgical care is a must

                                                                                                        Questions

                                                                                                        Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                                        Summary and Conclusionsbull It is truly all about the

                                                                                                        patient

                                                                                                        bull Team effort and framework is needed by design

                                                                                                        bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                                        bull Trauma centers save lives

                                                                                                        • Welcome to Trauma Tracks
                                                                                                        • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                                        • OBJECTIVES
                                                                                                        • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                                        • Current Outcomes for CY 2009
                                                                                                        • FRAMEWORK
                                                                                                        • ProfileCredentials of a Trauma Patient
                                                                                                        • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                                        • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                                        • Slide Number 10
                                                                                                        • Slide Number 11
                                                                                                        • Slide Number 12
                                                                                                        • Slide Number 13
                                                                                                        • Situation Awareness
                                                                                                        • Most Potentially Preventable Trauma Deaths are related to
                                                                                                        • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                                        • Optimizing Resuscitation Across the Continuum
                                                                                                        • Airway All trauma patients need oxygen until proven otherwise
                                                                                                        • Airway All unstable trauma patients need a definitive airway
                                                                                                        • Prehospital Intubation
                                                                                                        • Prehospital Intubation
                                                                                                        • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                                        • Bridge Devices 2010
                                                                                                        • Breathing All trauma patients need oxygen until proven otherwise
                                                                                                        • CT Scan for thoracic trauma
                                                                                                        • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                                        • Hemorrhage PEARL
                                                                                                        • Hemorrhage 5 Anatomic Areas of Origin
                                                                                                        • Hemorrhage Importance of Lactate amp BD
                                                                                                        • Persistent Acidosis Indicates
                                                                                                        • Base Deficit Categories
                                                                                                        • Uses of Base Deficit in Trauma Care
                                                                                                        • Resuscitation End Points
                                                                                                        • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                                        • Goal Directed Therapy PEARL
                                                                                                        • Optimizing Prehospital Resuscitation
                                                                                                        • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                                        • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                                        • Tourniquets 2010
                                                                                                        • Indications for Tourniquets
                                                                                                        • Intraosseous Infusion Devices 2010
                                                                                                        • Blood Substitutes 2010
                                                                                                        • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                                        • Pelvic Binders 2010
                                                                                                        • Optimizing ED Trauma Resuscitation (cont)
                                                                                                        • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                                        • Slide Number 47
                                                                                                        • Slide Number 48
                                                                                                        • ED Thoracotomy for Moribund Patients
                                                                                                        • Optimizing Resuscitation Across the Continuum
                                                                                                        • Damage ControlFocus on Physiology
                                                                                                        • Damage Control Patient Selection
                                                                                                        • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                                        • Questions
                                                                                                        • Summary and Conclusions

                                                                                                          Questions

                                                                                                          Change is the constant the Change is the constant the signal for rebirth the egg signal for rebirth the egg of the phoenixof the phoenix-- Christina Christina BaldwinBaldwin

                                                                                                          Summary and Conclusionsbull It is truly all about the

                                                                                                          patient

                                                                                                          bull Team effort and framework is needed by design

                                                                                                          bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                                          bull Trauma centers save lives

                                                                                                          • Welcome to Trauma Tracks
                                                                                                          • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                                          • OBJECTIVES
                                                                                                          • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                                          • Current Outcomes for CY 2009
                                                                                                          • FRAMEWORK
                                                                                                          • ProfileCredentials of a Trauma Patient
                                                                                                          • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                                          • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                                          • Slide Number 10
                                                                                                          • Slide Number 11
                                                                                                          • Slide Number 12
                                                                                                          • Slide Number 13
                                                                                                          • Situation Awareness
                                                                                                          • Most Potentially Preventable Trauma Deaths are related to
                                                                                                          • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                                          • Optimizing Resuscitation Across the Continuum
                                                                                                          • Airway All trauma patients need oxygen until proven otherwise
                                                                                                          • Airway All unstable trauma patients need a definitive airway
                                                                                                          • Prehospital Intubation
                                                                                                          • Prehospital Intubation
                                                                                                          • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                                          • Bridge Devices 2010
                                                                                                          • Breathing All trauma patients need oxygen until proven otherwise
                                                                                                          • CT Scan for thoracic trauma
                                                                                                          • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                                          • Hemorrhage PEARL
                                                                                                          • Hemorrhage 5 Anatomic Areas of Origin
                                                                                                          • Hemorrhage Importance of Lactate amp BD
                                                                                                          • Persistent Acidosis Indicates
                                                                                                          • Base Deficit Categories
                                                                                                          • Uses of Base Deficit in Trauma Care
                                                                                                          • Resuscitation End Points
                                                                                                          • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                                          • Goal Directed Therapy PEARL
                                                                                                          • Optimizing Prehospital Resuscitation
                                                                                                          • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                                          • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                                          • Tourniquets 2010
                                                                                                          • Indications for Tourniquets
                                                                                                          • Intraosseous Infusion Devices 2010
                                                                                                          • Blood Substitutes 2010
                                                                                                          • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                                          • Pelvic Binders 2010
                                                                                                          • Optimizing ED Trauma Resuscitation (cont)
                                                                                                          • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                                          • Slide Number 47
                                                                                                          • Slide Number 48
                                                                                                          • ED Thoracotomy for Moribund Patients
                                                                                                          • Optimizing Resuscitation Across the Continuum
                                                                                                          • Damage ControlFocus on Physiology
                                                                                                          • Damage Control Patient Selection
                                                                                                          • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                                          • Questions
                                                                                                          • Summary and Conclusions

                                                                                                            Summary and Conclusionsbull It is truly all about the

                                                                                                            patient

                                                                                                            bull Team effort and framework is needed by design

                                                                                                            bull Be familiar with the ldquoparadigm shiftrdquo in trauma care

                                                                                                            bull Trauma centers save lives

                                                                                                            • Welcome to Trauma Tracks
                                                                                                            • Role of the Nurse in Trauma ResuscitationMichele Ziglar MSN RNDirector Trauma amp Aeromedical ServicesShands at the University of Florida
                                                                                                            • OBJECTIVES
                                                                                                            • Shands at UF Level I Trauma Center(Oct 1 2004 ndash December 31 2009)
                                                                                                            • Current Outcomes for CY 2009
                                                                                                            • FRAMEWORK
                                                                                                            • ProfileCredentials of a Trauma Patient
                                                                                                            • FrameworkReadiness hyper-vigilance-- produces effective outcomes
                                                                                                            • FrameworkConsistent organization and clear cut communication produces effective outcomes
                                                                                                            • Slide Number 10
                                                                                                            • Slide Number 11
                                                                                                            • Slide Number 12
                                                                                                            • Slide Number 13
                                                                                                            • Situation Awareness
                                                                                                            • Most Potentially Preventable Trauma Deaths are related to
                                                                                                            • Framework We all need to know our A B C DsldquoGolden Rulesrdquo of Trauma
                                                                                                            • Optimizing Resuscitation Across the Continuum
                                                                                                            • Airway All trauma patients need oxygen until proven otherwise
                                                                                                            • Airway All unstable trauma patients need a definitive airway
                                                                                                            • Prehospital Intubation
                                                                                                            • Prehospital Intubation
                                                                                                            • The impact of prehospital ventilation on outcome after severe traumatic brain injury
                                                                                                            • Bridge Devices 2010
                                                                                                            • Breathing All trauma patients need oxygen until proven otherwise
                                                                                                            • CT Scan for thoracic trauma
                                                                                                            • Hemorrhage All trauma patients are bleeding until proven otherwise
                                                                                                            • Hemorrhage PEARL
                                                                                                            • Hemorrhage 5 Anatomic Areas of Origin
                                                                                                            • Hemorrhage Importance of Lactate amp BD
                                                                                                            • Persistent Acidosis Indicates
                                                                                                            • Base Deficit Categories
                                                                                                            • Uses of Base Deficit in Trauma Care
                                                                                                            • Resuscitation End Points
                                                                                                            • Eastern Association for the Surgery of TraumaPractice GuidelinesldquoEndpoints of Resuscitationrdquo
                                                                                                            • Goal Directed Therapy PEARL
                                                                                                            • Optimizing Prehospital Resuscitation
                                                                                                            • ldquoto resuscitate or not to resuscitaterdquo(hypotensive resuscitation)
                                                                                                            • PrehospitalTopicals 2010Hemostatic Field Dressing
                                                                                                            • Tourniquets 2010
                                                                                                            • Indications for Tourniquets
                                                                                                            • Intraosseous Infusion Devices 2010
                                                                                                            • Blood Substitutes 2010
                                                                                                            • Optimizing ED Trauma Resuscitation- stop the bleeding and minimize delay to OR IR
                                                                                                            • Pelvic Binders 2010
                                                                                                            • Optimizing ED Trauma Resuscitation (cont)
                                                                                                            • Optimizing Resuscitation- Interventions to Decrease the Need for Blood Transfusion
                                                                                                            • Slide Number 47
                                                                                                            • Slide Number 48
                                                                                                            • ED Thoracotomy for Moribund Patients
                                                                                                            • Optimizing Resuscitation Across the Continuum
                                                                                                            • Damage ControlFocus on Physiology
                                                                                                            • Damage Control Patient Selection
                                                                                                            • Neurological All unconscious trauma patients have brain injury until proven otherwise
                                                                                                            • Questions
                                                                                                            • Summary and Conclusions

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