Traumareanimation - MEDECdownload.medec.one/trauma.pdf · massage-A potential life-saving procedure...

Traumareanimation

alexander.dejaco@cynum.net, keine Interessenskonflikte

• Traumatic vs Cardiac arrest

• Evidenz & Epidemiologie

• Aktuelle Leitlinien & Handlungsempfehlungen

• Meaningful Interventions

Traumatic arrest

alexander.dejaco@cynum.net

Traumatic Arrest

Cardiac Arrest

Lecture of Gareth Grier (London’s Air Ambulance) @AGN Congress Graz 2016 alexander.dejaco@cynum.net

healthgrades.com firstaidreference.com medpagetoday.com

Reanimation? BLS, ALS …

URSACHEN:

• Hypovolaemie

Traumatic arrest

SMACC Force Dublin 2016, Intro Video alexander.dejaco@cynum.net

SMACC Force Dublin 2016, Intro Video SMACC Force Dublin 2016, Intro Video alexander.dejaco@cynum.net

URSACHEN:

• Hypovolaemie

• Hypoxie

Traumatic arrest

londonsairambulance.co.uk

Impact Brain Apnea

[1] Atkinson JL, Mayo Clin Proc. 2000 75(1) 37-47, Wilson et al., Resuscitation 2016 https://vimeo.com/152287249 “Impact Brain Apnea”, G.Davies alexander.dejaco@cynum.net

https://vimeo.com/152287249 “Impact Brain Apnea”, G.Davies

Impact Brain Apnea

John Hinds, “More Cases From The Races” lecture @SMACC Chicago alexander.dejaco@cynum.net

URSACHEN:

• Hypovolaemie

• Hypoxie

• Spannungspneumothorax

Traumatic arrest

Roberts & Hedges, Procedures in Emergency Medicine

URSACHEN:

• Hypovolaemie

• Hypoxie

• Herzbeuteltamponade

Traumatic arrest

forensicpathologyonline.com

URSACHEN:

• Hypovolaemie

• Hypoxie

• Herzbeuteltamponade

• Mit dem Leben unvereinbare Verletzungen

• Schweres SHT

Traumatic arrest

Meaningful interventions

URSACHEN:

• Hypovolaemie Blutverlust reduzieren

• Hypoxie Atemweg/Intubation

• Spannungspneumothorax bilat. Thorakostomien

• Herzbeuteltamponade Notthorakotomie

• Schweres SHT

Let’s see some numbers

Berlin – Kleber et al. 20141 (440 Px):

• 48% Hypovolaemie

• 13% Spannungspneumothorax

• 13% Hypoxie

• 10% Pericardtamponade

Traumatic arrest - EVIDENCE

[1] Kleber et al., Resuscitation 2014, 85, 405-410

• 34% Sturz aus >3m

• 22% Ueberrolltrauma

• 23% penetrierendes Trauma

• 74% der TCA versterben praehosp. • Zeit zum Eintreffen des Rettungsd. !! • ((Zeit bis Eintreffen im KH))

• 79% ROSC praehosp., 29% ueberleben • Davon 27% guter Neurologie • Von 440 Patienten nur 1 VF!!!

Berlin – Kleber et al. 20141 (440 Px):

• 64% hatten Fehler im praeklinischen Management – 49% Thoraxentlastung praeklinisch notwendig: nur 13% durchgefuehrt

– Instabiles Becken: nur 5% wurden praeklinisch stabilisiert

– 6% hatten Herzbeuteltamponade: KEINER wurde entlastet (Nadel oder Thorakotomie)

15% der Verstorbenen waeren sicher oder potentiell vermeidbar gewesen

[1] Kleber et al., Resuscitation 2014, 85, 405-410 alexander.dejaco@cynum.net

G. Davies 2013, London’s Air Ambulance:

[1] Kleber et al., Resuscitation 2014, 85, 405-410 alexander.dejaco@cynum.net

Leitlinien &

Handlungsempfehlungen

ERC Leitlinien 2015, “Cardiac arrest in special circumstances”

Traumatic arrest

2016 Leitlinien Australien & Neuseeland – ANZCOR 11.10.1

Traumatic arrest

ATACC – Anaesthesia Trauma &

Critical Care Manual 2014 - UK

Traumatic arrest

ATACC – Anaesthesia Trauma &

Critical Care Manual 2014 - UK

• Keine Herzdruckmassage

• Focus auf Blutungsstillung, Spannungspneumothorax, Atemweg

• Dann Resuscitative Thoracotomy, v.a. bei penetrierendem Trauma

Traumatic arrest

“One thing that is very clear is that this it not ALS!”

S3 Handlungsempfehlung Polytrauma, DGU

Traumatic arrest

S3 Handlungsempfehlung Polytrauma, DGU

Traumatic arrest

ERC 2015

Meaningful interventions

URSACHEN:

• Hypovolaemie Blutverlust reduzieren

• Hypoxie Atemweg/Intubation

• Spannungspneumothorax bilat. Thorakostomien

• Herzbeuteltamponade Notthorakotomie

• Schweres SHT

Meaningful Interventions (Periarrest) REBOA bei unstillbarer Blutung

REBOA: Resuscitative Endovascular Balloon occlusion of the Aorta • Beckenblutungen • Instabiler Patient • Kreislauf vorhanden

REBOA: Resuscitative Endovascular Balloon occlusion of the Aorta • Zur Stabilisierung/Zeitgewinn

londonsairambulance.co.uk alexander.dejaco@cynum.net

Stannard 2011 alexander.dejaco@cynum.net

Prytime REBOA Catheter

Wollongong CGD

INTECH Advanced, Heidelberg. Courtesy by Prof. Popp

Wollongong CGD alexander.dejaco@cynum.net

Meaningful Interventions Entlastung eines Spannungspneumothorax

NICE – National Institute for Health and Care Excellence – UK

Needle vs finger thoracostomy:

• IV catheters do not reach in up to 65% of the cases Can.J.Surg. 2010 53(3) 184, Prehosp.Emerg.Care 2009, 13(1) 14, J. Trauma 2008 64(1) 111, J. Trauma 2008 65(4) 964,

Accid. Emerg. Med. 1994 6 426, Injury 1996 5 321,, Arch. Surg. 2012 147(9) 813

• Anterior approach is not where you think it is Emerg. Med. J. 2003 20 383 (ED DOCS)

Emerg. Med. J. 2003 20 383 alexander.dejaco@cynum.net

www.smacc.net.au/2013/01/chest-decompression/ alexander.dejaco@cynum.net

Needle vs finger thoracostomy:

• IV catheters do not reach in up to 65% of the cases Can.J.Surg. 2010 53(3) 184, Prehosp.Emerg.Care 2009, 13(1) 14, J. Trauma 2008 64(1) 111, J. Trauma 2008 65(4) 964,

Accid. Emerg. Med. 1994 6 426, Injury 1996 5 321,, Arch. Surg. 2012 147(9) 813

• Anterior approach is not where you think it is Emerg. Med. J. 2003 20 383 (ED DOCS)

• If needle then lateral approach ANZ J. Surg. 2004 74(6) 420

www.smacc.net.au/2013/01/chest-decompression/ alexander.dejaco@cynum.net

Roberts & Hedges, Procedures in Emergency Medicine alexander.dejaco@cynum.net

resus.me alexander.dejaco@cynum.net

Meaningful Interventions Entlastung einer Herzbeuteltamponade

Resuscitative Thoracotomy?????????

Image from John Hinds (1980-2015) talk at SMACC Chicago 2015

2004, EMJ 22(1):22–24, Wise, Davies, et al., Emergency thoracotomy: ‘‘how to do it’’ 2009, Resuscitation, Nov;80(11):1270-4 Role of resuscitative emergency field thoracotomy in the Japanese helicopter emergency medical service system 2010, Injury. 2010 Jul;41(7):1008-12, Is pre-hospital thoracotomy necessary in the military environment? 2011, J Trauma. May;70(5):E75-8, Thirteen Survivors of Prehospital Thoracotomy for Penetrating Trauma: A Prehospital Physician-Performed Resuscitation Procedure That Can Yield Good Results 2013 Crit Care. 2013; 17(Suppl 2): P281, Sherren, Reid, et al. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service 2013 World J Surg (2013) 37:1277–1285, Sims et al. Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study 2014 AEM Volume 65, no. 3, Slessor and Hunter, To Be Blunt: Are We Wasting Our Time? Emergency Department Thoracotomy Following Blunt Trauma: A Systematic Review and Meta-Analysis 2014 Der Unfallchirurg 117:849–852, Puchwein et al., Erfolgreiche präklinische Thorakotomie bei einem 17-jährigen Mann 2014 Forrester et al., ATACC Trauma Course Manual 8th edition, anaesthesia trauma & critical care 2015 Injury, Injury, Int. J. Care Injured 46 (2015) 1738–1742, Puchwein et al, Clamshell thoracotomy and open heart massage-A potential life-saving procedure can be taught to emergency physicians An educational cadaveric pilot study 2015 World J Surg (2015) 39:1306–1311, Flaris et al., Clamshell Incision Versus Left Anterolateral Thoracotomy. Which One is Faster When Performing a Resuscitative Thoracotomy? The Tortoise and the Hare Revisited Usw…

2015 J trauma acute care surg 79(1):159–173, July 2015 Seamon et al

Das kann keiner

ueberleben!!!???

2015 J trauma acute care surg 79(1):159–173, July 2015 Seamon et al

Davies G. and Lockey D. J. Trauma: Thirteen survivors of prehospital thoracotomy for penetrating trauma: “A prehospital physician-performed resuscitation procedure that can yield good results”

• 15 Jahre retrospektiv, 13 ueberlebten, 11 davon neurologisch intakt

• Alle hatten eine Herzbeuteltamponade

• 7 Thorakotomien von Notfallmedizinern, 6 von Anaesthesisten

Puchwein et al. 2014 Der Unfallchirurg: “Erfolgreiche praeklinische Thorakotomie bei einem 17-jaehrigen Mann”

Meaningful Interventions Resuscitative Thoracotomy

SOP der London’s Air Ambulance: Prehospit. Notthorakotomie

SOP des SYDNEY HEMS Prehospit. Notthorakotomie

Was braucht man dazu?

4-E Prinzip:

• Expertise

• Equipment

• Environment

• Elapsed Time

Roberts & Hedges, Procedures in Emergency Medicine alexander.dejaco@cynum.net

Was braucht man dazu?

4-E Prinzip:

• Expertise

• Equipment

• Environment

• Elapsed Time

1. Immer eine “Clamshell”

2013 World J Surg (2013) 37:1277–1285, Sims et al., Bilateral Anterior Thoracotomy (Clamshell Incision), Is the Ideal Emergency Thoracotomy Incision:, An Anatomic Study

2013 World J Surg (2013) 37:1277–1285, Sims et al. Bilateral Anterior Thoracotomy (Clamshell Incision) Is the Ideal Emergency Thoracotomy Incision: An Anatomic Study

Youtube.com, “Thoracotomy”, umemergencymed

INTECH Advanced 2016, Heidelberg. Courtesy by Prof. Popp

Youtube.com, “clamshell thoracotomy”, Dr. Arvind Kumar

2013 World J Surg (2013) 37:1277–1285, Sims et al. alexander.dejaco@cynum.net

INTECH Advanced 2016, Heidelberg. Courtesy by Prof. Popp alexander.dejaco@cynum.net

ATACC manual version 8 alexander.dejaco@cynum.net

2. Perikard eroeffnen

Youtube.com, “Thoracotomy”, umemergencymed alexander.dejaco@cynum.net

forensicpathologyonline.com alexander.dejaco@cynum.net

Jetzt koennen wir aufhoeren!!

3. Blutendes Herz?

• Finger reinstecken • Harnkatheter • Klammern • Naehen

Youtube, Dr. Paul Coimbra alexander.dejaco@cynum.net

INTECH Advanced 2016, Heidelberg. Courtesy by Prof. Popp alexander.dejaco@cynum.net

INTECH Advanced 2016, Heidelberg. Courtesy by Prof. Popp Roberts & Hedges, Procedures in Emergency Medicine alexander.dejaco@cynum.net

4. Lungenverletzungen

Youtube, Dr. Paul Coimbra

4. Lungenverletzungen

“Hilar Twist”

5. Klemmen der Aorta

Wie lernt man das?

-”INTECH Advanced”, Universitaetsklinikum Heidelberg REBOA, ultraschallgestützte Pericardpunktion, Clamshell-Thorakotomie und Notfallnähte -SMACC conference, pre-conference workshop: cadaver lab (“social media and critical care”), www.smacc.net.au -PERT course (Pre-Hospital and Emergency Department Resuscitative Thoracotomy) Royal College of Surgeons, UK, https://www.rcseng.ac.uk/courses/course-search/resuscitative-thoracotomy

Zusammenfassung

Traumaarrest ist keineswegs aussichtslos

Wer ueberlebt hat haufig keinen neurol. Schaden

Umdenken: weg von “standard” ALS im Trauma-Arrest

Traumatic arrest

Traumareanimation - MEDECdownload.medec.one/trauma.pdf · massage-A potential life-saving procedure...

Documents

herbs for trauma.pdf

Supraspinatus musculotendinous architecture: a cadaveric ... · ii Supraspinatus musculotendinous architecture: a cadaveric and in vivo ultrasound investigation of the normal and

Interactive Cadaveric Dissection Guide - Clinician's View · Interactive Cadaveric Dissection Guide FINLEY’S Claudia R. Senesac ... deeper layers of the back muscles and the posterior

Cadaveric Simulation of Flatfoot and Surgical Corrective Techniques

Imaging Evaluation of Pediatric Chest Trauma.pdf

Cadaveric Simulation of Flatfoot and Surgical Corrective

Ballistic research techniques: visualizing gunshot ... · for ballistic research including, but not limited to, soap, gelatine, cadaveric human tissue, cadaveric animal tissue, andliveanimaltissue[13]

Ventriculoiliac shunt: a cadaveric feasibility study

Sports Massage, Esalen Massage, Massage Therapist | Fort

Selection of cadaveric donors in renal transplantation

US Guided and Cadaveric Dry Needling€¦ · US Guided and Cadaveric Dry Needling Author: César Fernández de las Peñas Created Date: 20160514213337Z

Single-position prone lateral approach: cadaveric

Cadaveric training courses

Atls - Apoyo Vital En Trauma.pdf

A cadaveric study on abdominal wall perforators from the

Laser Doppler Vibrometry measurements of human cadaveric

Burns & Trauma - Cadaveric bone marrow mesenchymal stem … · 2017. 8. 23. · Keywords: Burns, Cadaveric, Transplantation, Skin regeneration, Mesenchymal stem cells Background In

Extensor digitorum brevis manus: a Cadaveric Study and Review

OLYMPUS UPPER GASTROINTESTINAL CANCER CADAVERIC MASTERCLASS · OLYMPUS UPPER GASTROINTESTINAL CANCER CADAVERIC MASTERCLASS Option A: Three days - 4-6 September ... I would like to

The Posterior Epidural Ligaments: A Cadaveric and Histological