The Trauma Triad of Death

1
The Trauma Triad of Death
Michele K. Ziglar, RN, MSN Director of Trauma
Outreach University of North Carolina
Hospitals Trauma Program Chapel Hill, NC
2
Objectives

• Describe historical events leading to improved
  trauma care
• Discuss the 3 leading complications in
  multisystem injured patients
• Describe trauma triad treatment options

3
Pushing back the edge of death
4
Pushing back the edge of death
Societal Impact
5
Pushing back the edge of death
Constant Improvement of EMS System
6
Late 70s Early 80s

• Federal Funding under the Federal EMS Systems Act
  of 1973
• ED and ambulance equipment
• Initial treatment and triage protocols
• Decreased transport times
• Aggressive prehospital interventions en route
• Aggressive ED care

7
Pushing back the edge of death
Evolution of Trauma Systems
8
1980

• State Developed First Trauma Center Criteria
• Voluntary
• A derivation of ACS criteria

9
1982

• First Trauma Center Designations (Level I)
• Designation of hospitals NOT emergency departments

10
NC Trauma Centers
Wake
Pitt
Moses Cone
Duke
WFU Baptist
UNC
Alleghany
Northampton
Warren
Currituck
Ashe
Gates
Stokes
Surry
Caswell
Person
Rockingham
Vance
Camden
Hertford
Pasquotank
Granville
Perquimans
Halifax
Watauga
Wilkes
Chowan
Yadkin
Orange
Avery
Franklin
Bertie
Forsyth
Alamance
Mission
Durham
Mitchell
Nash
Guilford
Caldwell
Alexander
Davie
Edgecombe
Yancey
Madison
Iredell
Martin
Washington
Tyrrell
Davidson
Dare
Burke
Wake
Catawba
Randolph
Chatham
Wilson
Buncombe
Rowan
Mcdowell
Beaufort
Haywood
Pitt
Johnston
Greene
Lincoln
Hyde
Swain
Lee
Rutherford
Harnett
Cabarrus
Wayne
Henderson
Graham
Stanly
Montgomery
Moore
Cleveland
Polk
Gaston
Jackson
Mecklenburg
Lenoir
Craven
Transylvania
Macon
Cherokee
Pamlico
Richmond
Clay
Cumberland
Hoke
Jones
Union
Anson
Sampson
CMC
Cleveland
Duplin
Scotland
Carteret
Onslow
Robeson
Bladen
Pender
NC TRAUMA CENTERS
Columbus
New Hanover
New Hanover
Brunswick
Counties 100 Medical Schools 4 Acute Care
Hospitals 120 Managed Care Penetration 20-25
11
1987

• North Carolina Trauma Registry Established
• 8 trauma centers and 119 data points
• Today
• 10 trauma centers
• 11 additional hospitals
• 175 data points
• 62,000 patients (1994-1997)

12
NC Trauma Registry
Alleghany
Northampton
Warren
Currituck
Ashe
Gates
Stokes
Surry
Vance
Caswell
Person
Rockingham
Camden
Hertford
Pasquotank
Granville
Perquimans
Halifax
Watauga
Wilkes
Chowan
Yadkin
Orange
Avery
Franklin
Alamance
Bertie
Forsyth
Durham
Mitchell
Nash
Guilford
Caldwell
Alexander
Davie
Edgecombe
Yancey
Madison
Iredell
Martin
Washington
Tyrrell
Davidson
Dare
Burke
Wake
Catawba
Chatham
Randolph
Wilson
Buncombe
Rowan
Mcdowell
Beaufort
Haywood
Pitt
Johnston
Greene
Lincoln
Hyde
Swain
Lee
Rutherford
Harnett
Cabarrus
Wayne
Henderson
Graham
Stanly
Montgomery
Moore
Cleveland
Polk
Gaston
Jackson
Mecklenburg
Lenoir
Craven
Transylvania
Macon
Pamlico
Richmond
Clay
Cumberland
Hoke
Jones
Union
Anson
Sampson
Duplin
Scotland
Carteret
Onslow
Robeson
Bladen
TRAUMA REGISTRY LOCATIONS
Pender
Columbus
New Hanover
Trauma Centers
Brunswick
Additional Hospitals
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1993

• Statewide Trauma System Act of 1993 (G.S.
  131E-162)
• Identified NCOEMS as lead agency for development,
  monitoring, and compliance
• Mandated hospital participation
• Granted authority to establish administrative
  rules

14
1998

• Proposed Trauma Rules (10 NCAC 3D .2000)
• Updated trauma center criteria
• Codified designation process
• Established basic design for a state and regional
  trauma system plan with Regional Advisory
  Committees (RACs) as building blocks

15
Pushing back the edge of death
Golden Hour
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WARNING!
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WARNING!
Hypothermia
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Definition of Hypothermia

• Core temperature lt 35 degrees C
• Secondary accidental hypothermia

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Classification of Hypothermia

• Mild
• 32 to 35 degrees C

CV changes to maintain homeostasis
Cardiac conduction disturbances
Moderate 30 to 32 degrees C
Serious dysrhythmias heat production
conservation fail
Severe 28 to 30 degrees C
ACS Criteria
20
Significance of Hypothermia

• Hypothermia present in 21 to 66 of trauma
  patients upon ED admission
• 100 mortality lt 32 degrees C
• Increases cost, morbidity, mortality and length
  of stay

21
Factors Predisposing Trauma Patients to
Hypothermia

• Environmental
• external temperature
• long extrication times
• skin exposure
• air movement
• wet clothing

22
Predisposing Factors

• Extremes of Age
• very young
• elderly

23
Predisposing Factors

• Pre-existing Conditions
• Hypoglycemia
• Hypothyroidism
• Hypoadrenalism
• Diabetic neuropathy
• Peripheral vascular disease
• Anorexia nervosa

24
Predisposing Factors

• Treatment Related
• Exposure- wet clothing, surgery
• Fluid resuscitation
• Massive blood transfusions
• Immobilization

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Predisposing Factors

• Medications
• Alcohol
• Sedatives
• Narcotics
• Muscle relaxants
• Neuromuscular blocking agents
• Anesthesia

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Predisposing Factors

• Physiologic
• Open wounds
• Burns
• Shock
• Head injury
• Spinal cord injury

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Physiologic Changes
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Detrimental Effects of Hypothermia

• Metabolic Response
• CNS
• Cardiovascular
• Respiratory
• Renal Fluid Changes
• GI
• Hematologic

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WARNING!
COAULOPATHY
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Normal Hematologic Response to Injury

• Hypercoagulation
• Clotting factors are consumed ? promotes clotting
  dysfunction

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Etiology in Trauma

• Homeostatic (clot formation)
• Platelet dysfunction secondary to hypothermia and
  metabolic acidosis
• Dilutional due to volume replacement
• Secondary to excessive fibrinolytic activity as
  in DIC
• Decreased hepatic production of clotting factors

32
Temperature Related Coagulopathies
Platelet dysfunction
Enhanced fibrinolytic activity
Alteration in enzyme functions
33
Contributing Variables in Hypothermia Related
Coagulopathy

• Common consequence of massive fluid and
  transfusion resuscitation
• Crystalloids dilute available coagulation factors
• Banked blood low in platelets clotting factors
• Fluids/transfusion not warmed exacerbates
  hypothermic cycle

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WARNING!
Metabolic Acidosis
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Metabolic Acidosis in Trauma

• Primary result of
• loss of O2 carrying capacity
• Decreased cardiac output resulting from
  inadequate preload

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Causes of Acidemia O2 Debt Accumulation in
Trauma Patients

• Washout of acidotic blood from previously
  under-perfused tissue beds
• Continued bleeding
• Myocardial dysfunction
• Inadequate volume resuscitation

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Metabolic Acidosis Oxygen Supply-Demand Imbalance

• ? serum pH
• ? base deficit
• ? serum lactate

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Blood Gas Interpretation
Respiratory Acidosis
Metabolic Alkalosis
Normal Ranges
26 HCO3 22
45 PaCO2 35
Metabolic Acidosis
Respiratory Alkalosis
7.35 pH 7.45
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Acidosis Deleterious Effects on the Body

• Vasodilatation
• Myocardial depression
• Hyperkalemia
• Shift of oxyhemoglobin dissociation curve to the
  left
• Confusion, stupor

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Persistent Acidosis Indicates

• Continued bleeding
• Inadequate resuscitation
• Myocardial dysfunction

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Measures Directed at

• Enhancing O2 transport and O2 uptake
• Controlling the bleeding

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For Resuscitation to Occur

• Adequate perfusion and
• Tissue oxygenation must be restored

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Indicators of Anaerobic Metabolismand Acidosis

• ? serum pH
• ? base deficit
• ? serum lactate

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Base Deficit

• Amount of fixed base (bicarbonate) required to
  correct the pH of an aliquot of blood to 7.40 at
  37 C
• pH 7.40
• pCO2 40
• Hgb 15
• Temp. 37 Centigrade
• Base deficit 0

45
Base Deficit

• Excellent correlation of base deficit to lactate
  and pH
• Normalizes rapidly with adequate resuscitation
  and control of hemorrhage

46
Base Deficit Categories

• Normal (2 to -2)
• Mild (-3 to -5)
• Moderate (-6 to -9)
• Severe (-10 or higher)
• A base deficit of -6 is a marker of severe
• injury significant mortality

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Uses of Base Deficit in Trauma Care

• Assessing shock and efficacy of resuscitation
• Predicting
• abdominal injury
• transfusion requirement
• complications (RDS, MOF)
• mortality

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Treatment Options

• ATLS trauma resuscitation of
• crystalloids
• colloids
• surgery

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Treatment Options

• Re-evaluation of resuscitation end points
• B/P, HR, pulse pressure
• Mentation
• U/O
• Labs base deficit, serum lactate, serum pH

50
Treatment Options

• Identify cause of bleeding mechanical vs.
  nonmechanical bleeding
• Warm patient to reverse coagulopathies
• Blood, FFP, and Platelet replacement
• Avoid bicarbonate

51
Trauma Case Study

• 30 yr old male on MCC, hit head-on by MV driven
  by women who feel asleep
• EMS found patient face down with helmet on,
  initially conscious c/o of SOB, left leg
  severely crushed

52
Prehospital Phase

• Near amputation left leg
• Large filleted laceration left groin
• Decreased right BS, B/P 120/, HR 80, RR 22
• O2, immobilized, compression dressing to groin
  wound, attempted IVs

53
ED Phase Assessment

• Unconscious
• Decreased BS on R
• Copious amount of blood from L groin wound
• VS B/P 85/50, HR 130, RR 8, Temp. 35 C
• GCS 3, RTS 8
• PEARL
• Pale, diaphoretic
• Deformity L humerus fx

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ED Phase

• Diagnostics
• ABG pH 7.30, pCO2 29, paO2 86, HCO3 20 base
  deficit -6.5lactate 2.0
• Hct 32, Hgb 10.2
• X-rays

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ED Phase

• Interventions
• ETT, Ventilator
• Direct pressure to wounds
• Central peripheral IVs
• Fluid replacement- 6 liters warm LR NS, 6 units
  PRBCs
• Warmed patient

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OR Phase

• Left AKA
• Left common femoral vein repair
• Debride open humerus fx
• Fluid resuscitation- 6 FFP, 15 PRBCs, 14
  crystalloids

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Critical Care Phase

• Assessment
• B/P 60/30, HR 84, T 34.8 C
• Cool, pale, diaphoretic
• Blood oozing form AKA

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Critical Care

• Lab Diagnostics
• ABGs pH 6.96, pCO2 75, PaO2 64, HCO3 16, O2 sat
  77, base deficit -13.4, lactate 3
• Hgb 8.2, Hct 25, WBC 2.8
• PLT 66, Pt 22.4, APTT 126.2

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Outcome

• Returned to OR for revisions to stump
• Back to STICU
• Expired
• Traumatic shock
• Traumatic L pneumothorax
• Acute lung edema
• Cardiac arrest

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Trauma Case Study

• 39 yr old male sustained a GSW to right anterior
  neck with .22 caliber hand gun
• Hemodynamically stable during transport by EMS

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Emergency Department Phase

• At ED admission patient was conscious and
  combative with ETOH on breath, complaining of
  chest pain with large hematoma to R neck.
• Tracheal deviation to left
• Initial vital signs B/P 132/84, P 80, RR 26,
  Temp. 35 C
• PEARL
• GCS 15, RTS 12

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ED Diagnostics

• X-rays Cervical spine, chest and pelvis
• CT Scan neck and upper chest
• EKG
• ABGs
• Enzymes
• Admission lab panel
• Type and cross x 4 units

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ED Findings

• Radiology bullet embolus to region of R atrium,
  mediastinal hematoma, trachea deviation to left,
  pneumomediastinum, pneumopericardium
• EKG Inferior infarction
• Pulse oximetry 100
• ABG pH 7.37, pCO2 33, pO2 340, HCO3 18.6, Hgb
  13.5, base deficit -5.6, lactate 2.5
• BA 237

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ED Interventions

• Airway intubated with 7.5 ET
• IVs x 2 with LR and NS
• NG, indwelling urinary catheter
• Warming measures
• Diagnostics
• To OR within 2 hours

65
OR Phase

• Procedures
• Right neck exploration repair of right
  subclavian artery injury
• Bullet embolectomy of right coronary
  artery and closure
• Postoperative Diagnosis
• GSW to neck with bullet embolus to right
  coronary artery

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Outcome

• Patient admitted to CTICU in stable condition
• Extubated 2 hours postop bronchoscopy
  esophagoscopy performed
• Admitted to floor POD 1 barium swallow
  performed
• Discharged from hospital on POD 3

67
Trauma Case Study

• 28 yr. old male sustained traumatic amputation to
  left lower leg secondary to combine accident
• Transferred from field via flight team

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Emergency Department Significant Assessment
Findings

• Conscious alert to lethargic
• Pale/cool
• Traumatic amputation left lower leg
• B/P 100/67, HR 115, RR 24
• Temp. 35.6

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ED Diagnostics

• X-rays c-spine, chest, pelvis
• ABGs pH 7.32, pCO2 36, pO2 144, HCO3 18.1,
  base deficit -7.2, O2 Sat 99.3
• BA 195
• Toxicity screen cocaine, cannabis
• Hgb 9.8, Hct 28.7

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ED Interventions

• ETT and ventilator
• Fluid resuscitation 3 L crystalloids, 2 units
  PRBCs
• NG
• Indwelling urinary catheter
• Cleansed wound and compression dressing
• Warming measures

71
OR Phase

• Emergently transferred to OR (1/2 hour ED LOS)
• Incision and drainage/left below knee amputation

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Outcome

• Uneventful hospital stay
• OT, PT and substance consults
• Discharged ambulatory with crutches

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TEACHING POINTS

• The trauma triad can increase the mortality rates
  with virtually any injury
• Measures must be directed at enhancing O2
  transport and O2 uptake and controlling the
  bleeding
• For resuscitation to occur adequate perfusion and
  tissue oxygenation must be restored

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Questions?