Pupils, Posture, ... Slide 43 Slide 44 Trauma Anesthesia

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Trauma Anesthesia
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TRAUMA

• Epidemiology
• Trauma Systems
• Pathophysiology

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What is TRAUMA?

• Trauma is an injury caused by a physical force.
  Most often the consequences of motor vehicle
  crashes, falls, drowning, gun shots, fires and
  burns, stabbing, or blunt assault.
• American Trauma Society

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Trauma Mortality

• Trauma kills more people between the ages of
  1 and 44 than any other disease or illness.
  
• Nearly 100,000 people of all ages in the
  United States die from trauma each year.
• According to the National Center for Heath
  Statistics, trauma (unintentional injuries
  homicides) causes
• 43 of all deaths from age 1 to 4
• 48 of all deaths in ages 5 to 14
• 62 of all deaths in ages 15 to 24

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Trauma Morbidity and Mortality
Epidemiology of Trauma
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Trauma Morbidity
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Trauma Morbidity
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Trauma Mortality
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Morbidity by Mechanism
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Mortality by Mechanism
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Morbidity by Age and Mechanism
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Morbidity by Age and Mechanism
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Morbidity by Mechanism
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Violence Related Mortality
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Violence Related Mortality
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Trauma Morbidity
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Trauma Mortality
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Trauma Mortality
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Trauma Morbidity
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Trauma Mortality
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Trauma Morbidity
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Trauma Mortality
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TRAUMA Systems

• Injury Prevention
• Pre-hospital care
• Acute Care Trauma Centers
• Post-trauma Care and Rehabilitation

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TRAUMA Systems

• Injury Prevention
• Pre-hospital care
• Acute Care Trauma Centers
• Post-trauma Care and Rehabilitation

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Trauma Research
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TRAUMA Systems

• Injury Prevention
• Pre-hospital care
• Acute Care Trauma Centers
• Post-trauma Care and Rehabilitation

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History of Emergency Medical Services
Surgeon "mounting up" on a horse-drawn ambulance
leaving the yard of Bellevue Hospital, 1896.
Bellevue Hospital was the 1st City Hospital in
the country to dispatch ambulance services.
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Ambulance Service Pre-1960
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History of EMS

• Accidental Death and Disability The Neglected
  Disease of Modern Society National Academy of
  Sciences, National Research Council 1966.
• Pantridge JF, Geddes JS. A mobile intensive-care
  unit in the management of myocardial infarction.
  Lancet 1967 2(7510)271-273.
• Nagel EL, HirschmanJC, Mayer PW, Dennis F.
  Telemetry of physiologic data an aid to
  fire-rescue personnel in a metropolitan area.
  South Med J 1968 61(6)598-601.

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• 1966 The National Highway Safety Act (P.L.
  89-564) established national standards for
  training emergency medical technicians, and
  minimum equipment required on an ambulance
• Established the Department of Transportation as
  the lead federal agency to advance trauma safety,
  prehospital care, and acute care.

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History of EMS in the US
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Public Expectation
EMERGENCY
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Prehospital Emergency Medical Services
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TRAUMA Systems

• Injury Prevention
• Pre-hospital care
• Acute Care Trauma Centers
• Post-trauma Care and Rehabilitation

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TRAUMA CENTERS
LEVEL 1 LEVEL 2 LEVEL 3
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Regional Trauma Systems
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Trauma Scoring Systems
Physiologic scoring index of trauma severity

• TRAUMA SCORE
• BP, Refill, RR, RE, GCS
• GLASGOW COMA SCORE
• Eye Opening, Verbal, Motor
• INJURY SEVERITY SCORE
• Anatomic Severity Rating

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Trauma Scoring Systems

• REVISED TRAUMA SCORE

BP GCS RR VALUE
gt90 13 - 15 10 - 29 4 76 - 89 9 - 12 gt
29 3 50 -75 6 - 8 6 - 9 2 1 - 49 4
- 5 1 - 5 1 0 3 0 0
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Trauma Scoring Systems

• REVISED TRAUMA SCORE

RTS Probability of Survival
8 0.988 6 0.919 4 0.605 2 0.172 1 0
.071 0 0.027
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State of Florida Designated Trauma Centers
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Trauma Anesthesia
International Trauma Anesthesiaand Critical Care
Society
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TRAUMA Systems
Future of Trauma Systems
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Fate of Trauma Systems in the Future
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Fate of Trauma Systems in the Future
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TRAUMA

• Epidemiology
• Trauma Systems
• Pathophysiology

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Trauma Mortality
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IMMEDIATE HOURS DAYS
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Trauma Patient Profile

• Typical patient 1 - 40 yrs. - healthy
• Age extremes - coexisting diseases
• Increased Anesthesia Risk
• Altered Level of Consciousness
• ETOH and/or Drug Ingestion
• Full Stomach
• Hypovolemia
• Hypothermia
• Hypoxemia

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Mechanisms of Injury

• Blunt versus Penetrating Trauma
• Closed Head Trauma
• Neck and Airway Trauma
• Thoracic Trauma
• Abdominal Trauma
• Extremity Trauma
• Thermal - Haz Mat - Other

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PRIMARY SURVEY

• AIRWAY
• BREATHING
• CIRCULATION

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INITIAL RESUSCITATION

• AIRWAY
• Position / ETT
• BREATHING
• O2 / Vent
• CIRCULATION
• STOP Severe Bleeding

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SECONDARY SURVEY

• AIRWAY Maintenance
• C-Spine Stabilization Awy Position / ETT
• BREATHING Support
• O2 / Vent, Seal Chest Wound, Chest Tube
• CIRCULATORY Management
• STOP Bleeding, IV, Shock, EKG Status
• DISABILITY Status
• CNS Function, Pupils, Posture, Movement

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SECONDARY SURVEY

• AIRWAY Maintenance
• C-Spine Stabilization
• Awy Position or ETT
• Alternate Awys.
• Cricothyrotomy
• Suction

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SECONDARY SURVEY

• BREATHING Support
• High flow Supplemental O2
• Assist Ventilation prn
• Seal Open Chest Wound
• Decompress Tension Pneumo
• Insert Chest Tube
• Stabilize Flail Segment

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SECONDARY SURVEY

• CIRCULATORY Management
• STOP Bleeding
• Multi Large Bore IVs
• Fluid Resuscitation
• O-Negative Packed Cells
• Grade Shock-BP, Pulses, Refill
• EKG Status

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SECONDARY SURVEY

• DISABILITY Status
• CNS Function
• GCS - Eye / Verbal / Motor
• AVPU
• Posture
• Decorticate
• Decerebrate
• Pupils
• Movement

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Preanesthesia History

• Info from and about the scene
• Info about the accident or injury
• Past medical/surgical history
• Allergies, meals, meds, immunizations
• Substances of abuse
• ETOH -Cocaine -Opioids
• Marijuana -Inhalants -PCP

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Pre-Op Preparation for Trauma

• AIRWAY Management
• SHOCK Resuscitation
• Preanesthesia History
• Physical Assessment
• Monitoring / Fluids / Blood

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Physical Examination

• Primary Secondary Survey
• Particular focus on
• AIRWAY- face, mouth, neck
• RESPIRATORY- chest, diaphragm
• CARDIAC- chest, bleeding, IV access
• NEURO- ?LOC, GCS scores, pupils, motor
• LABS
• SMAC, Type Cross, ABG
• C-spine, CXR, CAT, MRI

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MONITORING

• Standard Monitors
• EKG -BP -SaO2 -Temp
• Urine -EtCO2 -NMB -A-line
• Secondary Monitors
• ICP -CVP -PA cath -LABs
• Room set up - Trauma cart
• Monitors -Airway -Warmers -Lines

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TRAUMA ANESTHESIA

• International Trauma Anesthesia and Critical Care
  Society

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