Trauma Case Based Pr

Trauma Case Based Trauma Case Based PresentationPresentation

S. MountainAdult Critical Care Fellow

Feb. 14, 2008

The Case (A True Story)The Case (A True Story)

It’s 0200, and you are on call. Thankfully, you have managed to make it home, and are in your warm bed, fast asleep, when your pager goes off. You wake up with your usual instant alertness, and call the number back.

The CaseThe Case

It’s the trauma surgeon on call. He says he is calling to give you a heads up on a case that is just coming out of the O.R. “You better come in,” he says. “This is a young guy who had the worst liver smash I have ever seen in anyone who survived. He has required a massive transfusion, and is going to need significant ongoing support.”

The CaseThe Case

You leap into your scrubs and head in to the unit. You get there a few minutes after the patient has arrived in the unit. The on call resident is going through the chart, and tells you the story.

The CaseThe Case

The patient is a 22 year-old previously healthy man, visiting Whistler from Spain. He was in the bike park today, and took a jump, landing badly on his handle bars. He was wearing a helmet, and didn’t hit his head, or suffer any loss of consciousness. Nevertheless, he required ambulance evacuation from the bike park to the Whistler clinic, where he received 8 units of PRBCs and 2 units of crystalloid for hypotension and anemia, and transport was initiated due to a grossly positive FAST.

The CaseThe Case

He was transported by helicopter to VGH. On his arrival he was very pale, but his GCS was 15, and he denied neck pain, but complained of abdominal pain.

After initial assessment and central line placement, he was taken rapidly to the O.R.

The CaseThe Case

On opening his abdomen in the O.R. a massive hemoperitoneum was evacuated, most of it into the Cell Saver.

The O.R. was long and complicated, with initial hemostasis and exposure being achieved with a Pringle maneuver, a Katell maneuver, and a Kocher maneuver.

Question 1Question 1

Naisan – what are Pringle, Katell, and Kocher’s maneuvers?

Pringle ManeuverPringle Maneuver

Pringle Maneuver.ram

Kocher ManeuverKocher Maneuver

Kocher Maneuver.ram

The CaseThe Case

Ongoing hemodynamic instability and massive transfusion required further exploration, and a period of veno-venous bypass. Eventually reasonable hemostasis was achieved after packing of the abdomen, and the patient was transferred to the ICU with an open abdomen and 3 hemovacs. Injuries identified intraoperatively were a Grade 5 hepatic injury, controlled with packing and a right hepatectomy, and a hemorrhagic duodenum, possibly secondary to manipulation.

Grading Liver InjuriesGrading Liver Injuries

The CaseThe Case

At this point, you are getting tired of listening to the history, and want to get a look at the patient.

Question 2 – Steve - What is your initial approach to assessing the trauma patient transferred to the ICU? Does it differ from the initial assessment of a trauma patient in emerg? If so, how?

Initial approach to the trauma patient being Initial approach to the trauma patient being transferred to the ICUtransferred to the ICU

Initial management of the trauma patient. Richards CF; Mayberry JC Crit Care Clin 2004 Jan;20(1):1-11.

ATLS for Doctors Student Course Manual, 1997, pp23-44

Primary Survey (ABCDE)– Airway - including assessment of level of consciousness. RSI w/ C-spine

stabiization.– Breathing - needle thoracostomy prn at this stage.– Circulation - assess volume status, obtain vascular access, compress

external bleeding, resuscitate, search for hidden bleeding.– Disability - GCS prior to sedation if possible, cerebro-protective measures

if necessary.– Exposure, environment - search for secondary injuries, warm.– Initial radiographs and procedures - C-spine, chest, chest tubes, FAST.

Initial approach to the trauma patient being Initial approach to the trauma patient being transferred to the ICUtransferred to the ICU

Secondary survey– Repeat exam; “tubes and fingers in every orifice”– Get more history, including collateral, mechanism, energy

transfer.– Further imaging if stable.

Tertiary survey– Repeat exam.– Reassess resuscitation.– Review imaging, labs, add on and repeat as necessary.– Monitor for compartment syndromes associated with

resuscitation, hypothermia and coagulopathy.

The CaseThe Case

After your initial assessment, you ask the resident to evaluate the patient for other injuries, while you review the history. He replies “I can just get the list of other injuries from the trauma team records. They do such a complete assessment anyway, it is redundant for us to go over everything again.”

Question 3 – Steve – Is the resident right, or is there evidence to support the value of a tertiary survey in the ICU?

What is the evidence to support the value of a tertiary What is the evidence to support the value of a tertiary survey?survey?

Implementation of a tertiary trauma survey decreases missed injuries. Biffl WL; Harrington DT; Cioffi WG J Trauma 2003 Jan;54(1):38-43.

~ 7,000 trauma patients, pre and post TS implementation. MIs decreased from 2.4% to 1.5% overall, and from 5.7% to 3.4% in

TICU patients, after TS implementation. Patients with MIs were slightly older (49 vs. 45 years; > 0.05) and had higher Injury Severity Scores (21 vs. 10; < 0.05) than patients without MIs. Sixty percent of MI patients had brain injuries, 56% were admitted to the TICU, and 26% went directly from the emergency department to the operating room. The large majority of MIs in the POST period were detected in patients not undergoing timely TS.

CONCLUSION: ICU patients-particularly brain injury victims and those undergoing emergent surgical procedures-appear to be at highest risk for MI. Implementation of a standardized TS decreased MIs by 36% in our Level I trauma center, and more timely TS would likely have further reduced MIs. A TS should be routine in trauma centers.

The CaseThe Case

You leave the room and sit down to examine the anesthesia record, confident that this is where the best information will be recorded. You are a bit shocked by the number of blood bank stickers on the records, and start to add up the transfusions. The grand total when you’re done is:

The CaseThe Case

25 litres of crystalloid45 units of PRBCs41 units of platelets20 units of FFP8 liters of fluid through the Cell

Saver

The CaseThe Case

You cleverly deduce that this patient has required a significant resuscitation, and is very likely to need more. You glance up at the hemovacs, and indeed notice that they are all filling up with blood fairly quickly.

Question 4 – Dave - What is your approach to massive transfusion for the trauma patient? In what order and what proportions do you use blood products and adjunctive treatments?

The CaseThe Case

You then notice that there is blood in the foley catheter. The post-op INR comes back at 2.1. You turn your attention to correcting the obvious coagulopathy.

Question 6 – Yoan – What are the main causes of coagulopathy in the multiply injured patient?

Coagulation defectsCoagulation defects

Coagulation Defects: EtiologiesCoagulation Defects: Etiologies


Question 7 – Yoan – What is the “lethal triad”? Draw the “bloody vicious cycle”.

The Lethal Triad/Bloody Vicious CycleThe Lethal Triad/Bloody Vicious Cycle


Naisan - Is there any evidence demonstrating benefit to active internal rewarming in trauma models? Are the authors trustworthy enough to consider the evidence valid?

The CaseThe Case

Further review of the anesthetic record reveals that the patient received two separate dose of Factor VIIa intraoperatively; first 4.8 mg, then 2.4 mg later in the case.

Question 9 – Yoan - How does rFVIIa work? Is there evidence to support its use in trauma patients?

RFVIIa MechanismRFVIIa Mechanism

At pharmacological doses, rFVIIa binds to the surface oflocally activated platelets following vascular injury, directly activating factor X,and thereby enhancing localized thrombin generation and formation of a stable fibrin clot only at the site of vascular injury.

RFVIIa evidenceRFVIIa evidence

R FVIIa evidenceR FVIIa evidence



Rfactor VIIaRfactor VIIa


The CaseThe Case

With the above measures, you start to catch up with the ongoing bleeding, and things slow down for a bit. The resident comes out of the room and asks you why the surgeons didn’t just finish the job while they were in the O.R., instead of exposing the patient to the risk of a second operation.


Gord - Describe the concepts underlying “damage control surgery (DCS).” What are the key issues for early ICU management?

Damage ControlDamage Control

American Naval term applied to ship’s absorbing injury and continued integrity of mission:

“The damaged ship undergoes rapid assessment and adequate repair to allow a return to the controlled environment of port”

Goal: Interruption of the Lethal Triad Variable indications… pH 7.2, Temp <34, 4L

EBL, 10L resusc fluid, onset of coagulopathy

Damage ControlDamage Control

Damage control surgeryDamage control surgery


Gord - What are some predictable complications in DCS patients, and what can be done to prevent them?

Complications in DCS patientsComplications in DCS patients

Preventing complications in DCS patientsPreventing complications in DCS patients

The CaseThe Case

With your ongoing resuscitative measures, the patient finally starts to stabilize. You grab breakfast and a coffee, and start to do rounds with the team. When you arrive at the bedside of the trauma patient, the nurse asks if they can discontinue cervical spine precautions, since the patient’s GCS was 15 on arrival in the E.R., and they did not complain of neck pain. The patient is now fully sedated.


Naisan – Can you D/C precautions based on the documented findings in emerg? What is your current approach to removal of C-spine precautions in the obtunded trauma patient? What is the evidence to support your approach?

C-spine injuries in blunt C-spine injuries in blunt traumatrauma

2-4% of blunt trauma injuries have associated C-spine injuries.

Missed or delayed diagnosis occurs in 4-8% of patients, 70% of whom have altered LOC.

C-spine ClearanceC-spine Clearance


The most common etiology of neurologic deterioration due to missed spinal injury was insufficient imaging studies (14/24). (ie had another study been added, the injury would not have been missed).

Other studies found 19-25% of C-spine injuries were missed by CT scan alone.


C-spine clearanceC-spine clearance

Previous guidelines (EAST) seem appropriate for bony clearance, but may not be adequate for ligamentous injury in the obtunded patient.

Recent reviews recommend MRI for evaluation of potential ligamentous injuries in patients who are at high risk based on mechanism, and who will remain obtunded for > 48 hrs. Not cost effective for all patients.

CT alone can miss a significant number of ligamentous injuries.

Studies of multislice CT vs. MRI need to be done.

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