Trauma Medical Director St. Lukes Hospital of Kansas City No financial relationships creating a conflict of interest to report Define the anatomy and physiology of Traumatic Brain Injury (TBI)
Explain the concept of the Monroe-Kellie Doctrine
Interpret the Brain Trauma Foundation guidelines for EMS treatment of TBI Discuss EMS strategies for managing injured patients
Compare and contrast City vs. Country challenges in managing injured patients
Suggest strategies for the EMS management of trauma patients Golden hour 30% late 20% immediate 50% 0% 20% 40% 60% 80% 100% 120% 0mi n 30mi n 60mi n 120mi n 180mi n Time (min) %
D e c l i n e Urban Rural injury related deaths are 40% higher in rural communities than in urban areas Center for Rural Care Fact Sheet University of North Dakota 2003 Methods: Retrospective Review of Autopsy/ME Database Comparing outcomes urban SDC vs rural VT All fatalities were reviewed ISS Age Cause of death Mechanism of Injury Comorbidities
Rogers et al, Arch Surg 1997 San Diego Vermont Cases 248(41%) 103(72%)* ISS 54 39* Age 33 45* Blunt/Pen(%) 69/31 49/51* Rogers et al, Arch Surg 1997 *p < 0.05 San Diego Vermont Cases 243(40%) 23(16%)* ISS 52 33* Age 33 46* Blunt/Pen(%) 61/39 96/4* Rogers et al, Arch Surg 1997 *p < 0.05 Rural patients are more likely to die at the scene, are less severely injured and are older
Rural patients surviving 24 hours before death are older, less severely injured, have more co-morbidities and are more likely to die of MOSF compared to urban patients Rogers et al, Arch Surg 1997 CITY COUNTRY 911 system local Paid, staffed vehicles Trauma Centers close Training Lots of resources Ground transport ALS 911 system county Volunteer Longer distances Training difficult Limited resources Helicopter transport BLS
CITY COUNTRY C.A.B.
load n go A.B.C.D.E.
stay n play Circulation & Hemorrhage control Airway Breathing AIRWAY & C-spine Control BREATHING CIRCULATION & Bleeding Control DISABILITY - Neurologic Assessment EXPOSURE - Prevent Hypothermia www.cdc.gov/Fieldtriage Visually inspect Sweep clear with gloved hand Aggressive suctioning Avoid Hypoxemia Severe Trauma Bleeding -- Consumption CRYSTALLOIDS TRANSFUSION DILUTION HYPOTHERMIA COAGULOPATHY M J Cohen, UCSF ACIDOSIS COAGULOPATHY HYPOTHERMIA DEATH Triad of Death Maintain mission integrity: Keep the patient alive
Recognition of the triad
Rapid Transport to the nearest appropriate hospital (trauma center) Preservation INJURY Hemorrhage Control RESUSCITATION time Immediate vs. delayed fluid resuscitation for hypotensive patients with penetrating torso injuries Bickell WH, Wall MH, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL Dept of Emergency Services, Saint Francis Hospital, Tulsa, OK USA N Engl J Med 1994 Oct 27;331:1105-9
598 patients; BP < 90; prospective, randomized Standard vs. limited resuscitation (prior to OR) by EMS 2480 mLs vs. 375 mLs IV fluids Standard: 38% mortality (p=0.04) & 30% morbidity Limited: 30% mortality and 23% morbidity Normotensive = No IV fluids Hypotensive = IV fluids until Palpable radial pulse Improved mentation MAP ~ 50 mm Hg; SBP ~ 80 mm Hg
Controlled IV fluid boluses 25 500 mL
Hypotension is almost never due to brain injury or hypovolemia from brain hemorrhage.
Exsanguination can occur from scalp laceration
Hypotension (SBP < 90 for 5 min) doubles brain injury mortality (60% vs. 27%) additional hypoxia increase mortality to 75% Goal: Maintain SBP > 90 mm Hg; MAP > 65 Treatment Correct hypotension with isotonic fluids 0.9% Normal Saline Lactated Ringers (LR)
Consider hypertonic saline (3%) if GCS < 8 250 mL 500 mL bolus Established EMS system with goal of getting the right patient to the right place in the right amount of time Goal Limit pre-hospital time Transport vehicle quickest means to closest center Transport to facility which has: CT scan capabilities ICP monitoring Neurosurgical Care
The perfect hemostatic dressing does not exist. Chitosan (anthropod skeletons) 79 97% success rate Must adhere well to wound Is not flexible, difficult to pack Works best on superficial, flat wounds
Kaolin volcanic rock Absorbs water in wound Concentrates factors, platelets In powder form heat created
Problem solved Gauze pads impregnated Require 2-5 mins pressure
Activates factor XII ONLY PRODUCT ENDORSED BY THE TACTICAL COMBAT CASUALTY CARE COMMITTEE OF DoD MAST Blanket or Sheet 1 gram over 10 minutes First dose within 3 hours of injury Second dose: 1 gram over 8 hours Trauma=unstable spine injury=spinal cord injury=permanent neurological deficit=bad.
Any additional movement of the neck/back may cause an injury that was not present immediately following the initial traumaor it may worsen an injury that was there prior to any subsequent medical intervention.
Further injury is avoided by immobilizing the spine.
Immobilization of the spine is safe.
Medicolegal issues prevent us from changing.
Pressure sores/tissue hypoxia
Good evidence that even short time periods on a board cause tissue hypoxia at contact points as well as pressure wounds
Wounds become worse with elderly and severely injured folks who cant readjust on board (aka spinal cord injured patient!) Linares HA, Mawson AR, Suarez E, Biundo JJ. Association between pressure sores and immobilization in the immediate post-injury period. Orthopedics. 1987;10:571-3. Sheerin F, de Frein R. The occipital and sacral pressures experienced by healthy volunteers under spinal immobilization: a trial of three surfaces. J Emerg Nurs. 2007;33:447-50. Cordell WH, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995;26:31-36. Berg G, Nyberg S, Harrison P, Baumchen J, Gurss E, Hennes E. Near-infrared spectroscopy measurement of sacral tissue oxygen saturation in healthy volunteers immobilized on rigid spine boards. Prehosp Emerg Care. 2010;14:419-24. Walton R, et al. Padded vs. Unpadded Spine Board for Cervical Spine Immobilization. Acad Emerg Med. 1995 Aug;2(8):725-8. Increased pain Healthy subjects placed on boards developed numerous complaints when on boards for short times (headaches, back, neck pain, dizziness, nausea)
Barney RN, Cordell WH, Miller E. Pain associated with immobilization on rigid spine boards. Ann Emerg Med. 1989;18:918. Lerner EB, Billittier AJ, Moscati RM. The effects of neutral positioning with and without padding on spinal immobilization of healthy subjects. Prehosp Emerg Care. 1998;2:112-6 Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994;23:48-51
We should NOT be immobilizing penetrating trauma.
Increases mortality and clear support from all parties involved (AANS, ACS-COT, NAEMSP, NAEMT, ATLS/PHTLS etc..)
Rhee P, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma. 2006;61:1166-1170
Rates for C-spine Fx: GSW (1.35%) Blunt Assault (0.41%) Stab Wound (0.12%). Rates of Spine Cord Inj: GSW (0.94%) Blunt Assault (0.14%) Stab Wound(0.11%) Rhee P, et al. Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault. J Trauma. 2006;61:1166-1170
Dont get shot in the spinal cord.. Neurologic deficits from penetrating assault were established and final at the time of presentation. Concern for protecting the neck should not hinder the evaluation process or life saving procedures. Dont waste time on scene packaging..just go.
There are no data to support routine spine immobilization in patients with penetrating trauma to the neck or torso.
There are no data to support routine spinal mobilization in patients with isolated penetrating trauma to the cranium.
Spine immobilization should never be done at the expense of accurate physical examination or identification and correction of life-threatening conditions in patients with penetrating trauma.
Stuke LE, Pons PT, Guy JS, Chapleau WP, Butler FK, McSwain NE. Prehospital spine immobilization for penetrating trauma--review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma. 2011;71:763-9; discussion 769-70.
Unwarranted spinal immobilization can expose patients to the risks of iatrogenic pain, skin ulceration, aspiration and respiratory compromise, which in turn can lead to multiple radiographs, resulting in unnecessary radiation exposure, longer hospital stay and increased costs. The potential risks of aspiration and respiratory compromise are of concern because death from asphyxiation is one of the major causes of preventable death in trauma patients. Kwan I, Bunn F, Roberts I. Spinal immobilization for trauma patients. Cochrane Database of Systematic Reviews. 2009;1:1-15
Reduce amount of on-scene personnel.
Reduce amount of patients lifted from ground on LSB who are already ambulatory.
Reduce amount of awkward positions providers place themselves in to extricate otherwise well patients from vehicles.
Reduce scene times by eliminating time spent immobilizing to board. (cot straps are quick!...LSB strapping is NOT quick) Decreased awkward extrication of stable patients who could self-extricate Less resources/manpower needed (two folks and a cot for most minor MVCs with neck pain). Less scene time when using cot straps and not securing head. More exposure/access to patient enroute. More comfort for patient. Saves patient from ED doc who leaves on board in hospital. Decrease radiological studies. Decreases cost. Decrease in resistance to placing a c-collar in elderly or borderline patient when not mandated to use LSB.
Despite the long-standing history and culture of spinal immobilization with a backboard and cervical collar, using the best evidence available, many abroad and in the US believe the risk-benefit analysis shows that the proven harm is much worse than the theoretical, but unproven, benefit of the backboard.