What is new in trauma management?

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Notes from lecture in Combined scientific meeting  by Ken Harrison

What is new in trauma management?

6 points:
1.        Airway devices
2.        Hyperoxaemia
3.        Stop the bleeding
4.        Following the patient
5.        Induction drugs
6.        Analgesia

1.New airway devices for use in the field :
a.        Various types of LMA( Supreme, igel )
b.        Various types of Videolaryngoscopes ( Airtraq, McGrath)

2. Hyperoxaemia
Hypoxaemia & hyperoxaemia are both  harmful in neurotrauma .
High flow O2 may kill a patient with COAD.

3.Stop the bleeding
Damage control resuscitation:

Primary survey

Airway+ Cervical spines control
Breathing+Ventilation
Circulation +control bleeding
Disability+Neurological evaluation
Exposure + But keep warm

•        Repeat primary survey until stable.
•        Give volume by boluses.
•        Give warm normal Saline 20ml/kg as bolus , as an assessment of blood loss estimation , watch the heart rate & blood pressure.
•        After the 2nd  bolus , start to give blood.
•        Reassess often, do ABGs, FBC,  Coags.
There is a paradigm shift ( EMA Article 2008) :
•        Haemorrhage control
•        Contamination containment
•        Definitive surgery to be delayed 24 to 72 hours.

Remember the Lethal triads :
Coagulopathy + Hypothermia+ Acidosis.

Methods  used to stop bleeding:
Tourniquet, Novel Topical hemostatics, Permissive hypotension.

Methods used to prevent hypothermia ( Temperature <35’C):
1.        Use 2 Bair- huggers (hot air blower warmers)—one above and one below the patient.
2.        Keep the patient dry
3.        Warm all fluids.

Blood & products Transfusion:
Study showed that the ratio of FFP : PRBC near to 1:1 is ideal .
Increasing the ratio of FFP: PRBC , the survivor rate is increased.

Hypotensive resuscitation/Permissive hypotension:

Definition:Keep blood pressure low to reduce bleeding until bleeding point is controlled.

4 groups of patients:
1.        Penetrating injury
2.        Blunt non head injury
3.        Blunt head only injury
4.        Blunt both head & body injury

1.        Management of Penetrating injury :
•        Keep radial pulse present is enough , put a pulse oximeter probe on the finger , if can pick up , it is enough perfusion. (Systolic BP about 60mmHg.)
•        Most important priority  is to stop the bleeding .
•        Go either to OR or Angio room to locate the bleeding point and stop it.
•        After the bleeding is stop , can replace the volume with 1/1/1 blood /FFP/Platelet.

2.        Management of blunt non head injury :
Same as for penetrating injury.

3.        Management of blunt head injury:
•        Give blood /fluids to keep MAP=90mmHg until bleeding is controlled.
•        MAP=90mmHg is equal to Systolic BP about 110mmHg.
•        CPP=MAP-ICP. To keep CPP about 60 mmHg , and ICP is <30mmHg ( ICP above 30mmHg, brain is not salvageable ) , the MAP need to be 90mmHg.

4.        Management of both head & body injuries:
Decide which one is going to kill the patient first, then treat that one first.

4.Following the patient around until stable  will improve his/her outcome.

5.Induction agents:
Use less of Midazolam , more of Ketamine is the recent trend in the European countries & USA.
Reasons:
•        Recent study had declared that for Ketamine, the effect on  ICP is not an issue.
•        Need to add a small dose of midazolam to prevent bad dreams.
•        It gives more stable hemodynamics.

6.Analgesia:
Adequate analgesia is important to reduce post traumatic stress disorder. Can use IV morphine or PCAs.

jstzr

外伤管理新进展是什么？