Trauma Webinar 1 - permissive hypotension; trauma system triage based on physiology, anatomy, special populations and mechanism.
We covered general topics and chest trauma specifically across 2 webinars.
We looked at the
Physiological, Anatomical, Special patient populations and Mechanistic parameters that determine whether patient go to a trauma centre. Different jurisdictions have slightly different rules but based on the above categories.
Popular topic for discussion. Essentially not much evidence for its use.
aiming for cerebral perfusion while maintaining the blood clot while arranging definitive care through a surgeon.
Not for brain injury / children
see entries in LIFL
There is no high level evidence to support this approach
Delayed fluid resuscitation/controlled hypotension — Questions remain whether reversal of hypovolemia or control of hemorrhage should take priority in trauma resuscitation.
A growing number of researchers describe aggressive fluid administration as ineffective and potentially harmful and suggest that
limited volume replacement that maintains minimally adequate organ perfusion may improve outcomes
This strategy has been referred to as delayed fluid resuscitation, controlled hypotension, permissive hypotension, hypotensive resuscitation, or controlled resuscitation,
targets early fluid resuscitation only to a SBP of greater than 70 mmHg.
Controlled hypotension may be beneficial in patients with hemorrhagic shock due to torso injuries from gunshot or stab wounds.
may be detrimental to blunt trauma patients with brain injury, as hypotension reduces cerebral perfusion and increases mortality
The rationale for improved outcomes with delayed fluid resuscitation is that aggressive fluid administration might, via
augmentation of blood pressure,
dilution of clotting factors, and
production of hypothermia,
disrupt thrombus formation and enhance bleeding
In one widely cited prospective study of 598 patients with penetrating chest injuries treated at a major trauma center, delayed fluid resuscitation until operative intervention to control bleeding was associated with a statistically significant improvement in patient survival (70 versus 62 percent in those given immediate fluid repletion)
subjects were primarily young and healthy, and the mean time from injury to operation was two hours, results that are not attainable in most circumstances.
In a preliminary analysis of a trial conducted at another major trauma center, 90 young adults with penetrating (n = 84) or blunt (n = 6) trauma resulting in at least one SBP reading below 90 mmHg, and hemorrhage requiring immediate laparotomy or thoracotomy, were randomly assigned upon arrival to the operating theater to resuscitation using a low-goal mean arterial pressure of 50 mmHg (LMAP group) or a high-goal mean arterial pressure of 65 mmHg (HMAP)
Among the patients excluded were those with traumatic brain injury.
Anesthesiologists did not intervene to lower the blood pressure of patients in the LMAP group whose MAP exceeded 50 mmHg. Patients in the LMAP group had lower postoperative mortality (6 versus 10 deaths), received fewer blood products (1594 versus 2898 mL), and did not develop coagulopathy or multiple organ failure (MOF), compared with seven cases of coagulopathy and two cases of MOF in the HMAP group.
However, there was no significant difference between the groups in overall mortality at 30 days.
Other results favoring controlled hypotension or controlled resuscitation for both penetrating and blunt trauma patients include European guidelines published in 2013 recommending a target SBP of 80 to 90 mmHg until major bleeding has been stopped in the initial phase following trauma without brain injury
Another randomized trial conducted by The Resuscitation Outcomes Consortium (ROC) published in 2015 concluded that controlled resuscitation (defined as SBP >70 mmHg) is achievable in out-of-hospital and hospital settings and may offer an early survival advantage in blunt trauma
The results of these studies notwithstanding, adoption of the strategy of delayed fluid resuscitation or controlled hypotension into clinical practice must be undertaken cautiously
Factors that should be considered when determining whether this strategy is appropriate include
the patient's mental status and
likelihood of intracranial injury,
likelihood of spinal cord injury (SCI),
underlying illness such as chronic hypertension and
proximity to a trauma center.
Further research to determine the appropriateness and effectiveness of this approach is needed
Based on current data, limiting fluid resuscitation to 1 L or less and moving directly to blood products appears to be the best strategy.
Nexus vs Canadian c spine rules vs pem approach
Nexus is 5 criteria - Neurology, evidence of intoxicating, eXtremity distraction, unconscious, spinal tender
nexus is less sensitive - 90% while CCSR is 95-99% sensitive - ccsr results in less imaging
Need to have an expert approach to children c spine imaging
essentially a combo of Nexus and ccsr can be used with high threshold to imaging because in the absence of multi trauma, nai or unconsciousness / mvc - the incidence of injury is extremely low.
plain film actually leads to increased CT usage because many false positives in the pediatric spine film.
generally observation with analgesia
mri first line test with orthodox consult or limited ct cspine of area of concern