Advanced Trauma Life Support

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1. Preparation
2. Triage
3. Primary Survey (ABCDEs)
4. Resuscitation
5. Adjuncts to primary survey & resuscitation
6. Secondary Survey (head to toe evaluation & history)
7. Adjuncts to secondary survey
8. Continued post-resuscitation monitoring & re-evaluation
9. Definite care.
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1. PREPARATION
A Pre-hospital phase
Receiving hospital is notified first.
Send to the closest, appropriate facility.
B In Hospital Phase
Advanced planning for the trauma pt arrival.
Method to summon extra medical assistance
Transfer agreement with verified trauma center established.
Protect from communicable disease.
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2. TRIAGE
A Multiple Casualties
no of severity & pt do not exceed the ability of
the facility.
B Mass Casualties
no & severity of pt EXCEED the capability of
the facility & staff.
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3. PRIMARY SURVEY
A : Airway with cervical spine protect.
B : Breathing
C : Circulation --control external bleeding.
D : Disability or neurological status
E : Exposure (undress) & Environment (temp control)
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PRIMARY SURVEY
Priorities for the care of Adult , Pediatrics
& Pregnancy women are all the same.
During the primary survey life threatening
conditions are identified and management is
instituted SIMULTANEOUSLY.

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A. Airway Maintenance with Cervical Spine

Protection.
* GCS score of 8 or less require the placement of definite
airway.
*Protection of the spine & spinal cord is the important
management principle.
*Neurological exam alone does not exclude a cervical spine
injury.
*Always assume a cervical spine injury in any pt with multisystem trauma, especially with an altered level of consciousness
or blunt injury above the clavicle.
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B. Breathing & Ventilation

* Airway patency does not assure adequate ventilation.

C. Circulation with Hemorrhage Control.

a. consciousness.
b. skin color
c. Pulse.
*external bleeding is identified & controlled in the
primary survey.
*Tourniquets should not be use.

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D. Disability ( Neurological Evaluation)

Simple Mnemonic to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Not forget to use also Glascow Coma Scale.

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E. Exposure / Environmental Control

*It is the pts body temp that is most important, not he
comfort of the health care provider.
*Intravenous fluid should be warm.
*Warm environment (room tem) should be maintained.
*early control of hemorrhage.

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4. RESUSCITATION
A. Airway
*definite airway if there is any doubt about the pts ability to
maintain airway integrity.

B. Breathing /Ventilation/Oxygenation
*every injured pt should received supplement oxygen

C. Circulation
*control bleeding by direct pressure or operative intervention
* minimum of two large caliber IV should be established
*pregnancy test for all female of child bearing age.
* Lactated Ringer is preferred & better if warm.
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5. ADJUNCT TO PRIMARY SURVEY &

RESUSCITATION
A. Electro-cardiographic Monitoring
B. Urinary & Gastric Catheter
1. Urinary catheter.
Urethral injury should be suspected if
*Blood at the penile meatus
*Perineal ecchymosis
*Blood in the scrotum
*High riding or nonpalpable prostate
*Pelvic fracture
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C. Monitoring
1. Ventilatory rate & ABG
2. Pulse oximetry
does not measure ventilation or partial O2 pressure
3. Blood pressure
poor measure of actual tissue perfusion.

D. X-Ray & Diagnostic Studies

C-spine, CXR, Pelvic film
Essential x-ray should not be avoid in pregnant pt.

*** Consider the need for patient transfer.

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6 SECONDARY SURVEY
Does not begin until the primary survey (ABCDEs)
is completed, resuscitative effort are well established
& the pt is demonstrating normalization of vital sign.
* Head to Toe evaluation & reassessment of all vital
signs.
* A complete neurological exam is performed including
a GCS score.
* Special procedure is order.
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History
A : Allergies.
M : Medication currently used.
P : Past illness/ Pregnancy.
L : Last Meal
E : Events/Environment related to the injury.
*blunt trauma/penetrating trauma/injuries due
to cold & burn/hazardous environment?
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PHYSICAL EXAMINATION
1. Head
Visual acuity
Pupillary size
Hemorrhage of conjunctiva and fundi
Penetrating injury
Contact lenses(remove before edema occurs)
Dislocation of lens
Ocular movement
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16

2. Maxillofacial Injury
no NG tube, definite airway?
3. Cervical Spine & Neck
*Pt with maxillofacial or head trauma should be presumed
to have and unstable cervical spine.
4. Chest
*elderly pt are not tolerant of even relatively minor
chest injury.
*Children often sustain significant injury to the
intrathoracic structure without evidence of thoracic
skeletal trauma.
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5. Abdomen
*excessive manipulation of the pelvic should be avoided.
6. Perineum/rectum/vagina
7. Musculoskeletal
8. Neurologic
* Protection of spinal cord is required at all times until a
spine injury excluded, especially when the pt is transfer.

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7. ADJUNCT TO THE SECONDARY SURVEY

include additional x-ray and all other special procedure.

8. RE-EVALUATION
Adult urine output 0.5ml/kg/hr
Pediatric urine output 1mg/kg/hr
*Pain relief -- IM should be avoid.

9. DEFINITE CARE

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Indication For Definite Airway

* Unconscious
* Severe maxillo-facial fracture
* Risk for aspiration : Bleeding/ vomiting
* Risk for obstruction : neck hematoma/laryngeal,tracheal
injury/ stridor
* Apnea : Neuromuscular paralysis/unconscious
* Inadequate respiratory effort:
tachypnea/hypoxia/hypercapnia/cyanosis
* Severe closed head injury need for hyperventilation
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Normal Blood Amount:

Normal adult blood volume : 7% of body weight
Normal blood volume for child : 8-9% of body weight

Hemorrhage Classification :
Class I Hemorrhage :

up to 15% loss

Class II Hemorrhage :

15-30% loss

Class III Hemorrhage :

30-40% loss

Class IV Hemorrhage :

>40% loss

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3 for 1 Rule
a rough guideline for the total amount of
crystalloid volume acutely is to replace each
ML of blood loss with 3 ML of crystalloid
fluid, thus allowing for restitution of plasma
volume lost into the interstitial &
intracellular space

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Initial Fluid Therapy

Normal Saline is preferred

* For adult 1-2 liters bolus

* For child 20ml/kg bolus
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Intraosseous Puncture/Infusion
Children less than 6 y/o for IV access is
impossible due to circulatory collapse or
for whom percutaneous peripheral venous
cannulation had failed on two attempt.

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Head Injury Classification:

Mild

: GCS 14-15

Moderate : GCS 9-13

Severe

: GCS 3-8

Coma = GCS score of 8 or less

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Diagnostic Peritoneal Lavage Indication

A. Change in sensorium--Head injury/alcohol/drug.
B. Change in sensation--Spinal cord injury.
C. Injury to adjacent structure--lower
ribs/pelvic/lumbar spine.
D. Equivocal physical examination.
E. Prolong loss of contact with patient anticipated.
*** Positive Test: >100,000 RBC/mm3, >500 WBC/mm3
or Gram Stain with bacteria
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Determining the level of quadriplegia

a. Raise elbow to level of shoulder -- Deltoid C5
b. Flexes the forearm -- Biceps C6
c. Extend the forearm -- Triceps C7
d. Flexes wrist & finger -- C8
e. Spread fingers -- T1
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Determine the level of paraplegia

a. Flexes the hip -- Iliopsoas L2
b. Extend knee -- Quadriceps L3
c. Dorsiflexes ankle -- Tibialis anterior L4
d. Plantar flexes ankle -- Gastrocnemius S1

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Thoracic Trauma
8 lethal Injuries
1. Simple pneumothorax
2. Hemothorax
3. Pulmonary contusion
4. Tracheo-bronchial tree injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Mediastinal traversing wounds.
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Fluid Therapy in
2nd or 3rd Degree Burn
(parkland formula)

Total amount of first 24 hours:

4 ml of Ringer lactate x BW(kg) x BSA
* give 1/2 in first 8 hrs
* 1/2 in remaining 16 hrs

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Referral to Burn Center

* 2nd or 3rd degree burn >10% BSA, pt under 10 or over 50y/o
* 2nd or 3rd degree burn > 20% BSA in other age group
* 2nd or 3rd degree burn of face/eye/ear/hands/feet/
genitalia/perineum or major joints
* 3rd degree burn >5% in any age group
* Significant electrical/lightning injury
* Significant chemical burn
* Inhalation injury
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Color Codes Triage Tag

RED : Most critical injury
YELLOW : Less critical injured
GREEN : No life or limb threatened injury
BLACK : Death or obviously fatal injury

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Priorities with multiple injuries

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1.

Thoracic trauma or tamponade

2.

Abdominal hemorrhage

3.

Pelvic Hemorrhage

4.

Extremity Hemorrhage

5.

Intra-cranial Injury

6.

Acute Spinal Cord Injury

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TRAUMA & MULTIPLE INJURY

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INJURY BIOMECHANICS AND

ACCIDENT PREVENTION
The magnitude of an injury is related to energy
transferred to the victim during the event, the
volume/area of tissue involved and the time
taken for the interaction

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ALCOHOL & DRUGS

TRAUMA DUE TO ALCOHOL IN ASSAULTS 60%
BURNS
HOMICIDES
30% - 50%
DROWNING
ROAD TRAFFIC ACCIDENT 10%
DEATH DUE TO ALCOHOL IN RTA- 1/3 OF DEATH (30%)
DEATH DUE TO ALCOHOL IN RTA- 20%

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WOUNDS
CLASSIFICATION

ABRASION OR GRAZES
CONTUSIONS , ECCHYMOSES OR BRUISES
LACERATIONS
INCISED WOUNDS / CUTS
PUNCTURE WOUNDS
GUNSHOT WOUNDS

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FALLS
Major determinant of injury and the chance of
death is directly proportional to the height fallen.
At impact the decelerating forces are
determined by the individuals mass , the nature
of the landing surface and the bodys orientation
on landing

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INJURY SEVERITY ASSESSMENT

Abbreviated Injury Scale (A.I.S) Severity of
Anatomical injury
Glasgow Coma Scale (G.C.S) Assess the
neurological state of mind
GCS + Systolic B.P + Respiratory rate -----
Revised Trauma Score

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GCS

Eye opening

4
3
2
1

Verbal Response

Spontaneously
to speech
to pain
none

Orientated
Confused
inappropriate words
incomprehensible sounds
none

5
4
3
2
1

Motor Response

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Obey commands
Localizes to pain
Flexion(withdraw)to pain
Abnormal flexion to pain
Extension to pain
None

- Total

6
5
4
3
2
1

/15
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ASSESSING MUSCLE POWER- the

MRC scale

No flicker movement
A flicker of contraction,but no movement
Movement, with gravity neutralized
Movement against gravity
Movement against added resistance
Normal power

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0
1
2
3
4
5

41

IMAGING & OTHER DIAGNOSTIC

AIDS
INITIAL X RAYS
CHEST
CERVICAL SPINE
PELVIS
THORACIC / LUMBAR VIEWS
FOR HEAD,SPINAL AND PELVIC INJURY CT SCAN
SKULL X RAY
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AFTER THE RESUSCITATION ROOM

Immediate aim of resuscitation is to assess & treat life threatening injuries

Patient with Patent Airways
Adequate Gas Exchange
Circulatory Status is normal
Long Bone Fractures Splinted
Cervical Spine Control maintained throughout
Identify the correct destination for the patient
Perform Surgical Intervention if needed
Full Monitoring & Resuscitation Equipment mandatory if to be transferred to
theatre
If to be transferred to another Hospital should be done appropriately
Regular updates should be supplied to the receiving specialists.

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PREHOSPITAL CARE & TRANSPORT

AMBULANCE SERVICES (land based vehicles,
Helicopters , fixed wing air craft)
PARAMEDICS

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RESUSCITATION IN THE A&E

DEPARTMENT
FIRST 10 MINUTES

------------------------
AIRWAY

CONTROL OF CERVICAL SPINE

ADVANCED AIRWAY TECHNIQUES

BREATHING

CIRCULATION

ANALGESIA & SPLINTING

NEXT PHASE

-----------------
PATIENT EXAMINED FROM TOP TO TOE

BACK & SPINE ARE EXAMINED

LOOKING FOR LOCALISED TENDERNESS/SWELLING / OR A STEP

PERINEUM IS EXAMINED

RECTAL EXAMINATION IS PERFORMED

NEUROLOGICAL EXAMINATION

EXAMINE FOR EVIDENCE OF SKULL BASE INJURY

MUSCLE POWER TESTED USING MRC SCALE

TENDON REFLEXES EXAMINED

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Abdominal trauma

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Overview

Epidemiology
Anatomy
Initial Evaluation
Blunt Abdominal Trauma
Penetrating Abdominal Trauma
Pediatric Abdominal Trauma

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Epidemiology
Blunt Abdominal Trauma
Blunt Abdominal Trauma = 66-75%
MVA leading cause

Penetrating Abdominal Trauma

30,708 deaths due to GSW in USA during 00
USA firearm deaths far exceeds all European
countries
Norway has highest European firearm death rate (1/5 of
USA)
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Epidemiology
Mortality
6-10% of all patients w/ Abdominal Trauma
However polytrauma may skew this figure

~50% of all OR deaths 1 due to ABD Trauma

Age
Peak 14-30 y/o

Gender
60:40 Males
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Overview

Epidemiology
Anatomy
Initial Evaluation
Blunt Abdominal Trauma (BAT)
Penetrating Abdominal Trauma
Pediatric Abdominal Trauma

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Anatomy
Peritoneal Cavity
Upper Half
Diaphragm
Expiration = Diaphragm rises to 4th intercostal space
Places intra-abdominal contents at risk from rib fracture

Liver & Spleen

Stomach & Transverse Colon

Lower Half
Small Bowel
Sigmoid Colon
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Anatomy
Pelvic Cavity
Protected by pelvic bones
Bladder, Rectum, Large Blood Vessels, +/- Uterus
Also at increased risk from pelvic fracture (esp. bladder)

Retroperitoneal Space
Tough to determine/examine but not to forget
Abdomial Aorta, IVC, Duodenum, Pancreas, Kidneys,
Ascending/Descending Colon.

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Overview

Epidemiology
Anatomy
Initial Evaluation
Blunt Abdominal Trauma
Penetrating Abdominal Trauma
Pediatric Abdominal Trauma

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Initial Evaluation
History
Unless ABC & Resuscitation required immediately

AMPLE history

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A Allergy
M Medications
P Past Medical History
L Last PO Intake
E Events leading to presentation

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Initial Evaluation
Pertinent History
MVA

Belted
Air Bag Deployment
Patients Position in Vehicle
Speed
Type of Collision ( frontal, side, rear )
Status of other Passengers

Fall
Height
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Initial Evaluation
Pertinent History
Penetrating

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Time
Type of Weapon (knife, handgun, shotgun, uzi)
Length of knife
Number of stab wounds & number shots fired

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Initial Evaluation
Physical Exam
Inspection
Fully Expose Patient
Abrasions & Contusions from restraint devices
Seat Belt sign (ABD or Chest)

Find source for Bleeding

Lacerations
Impaled Foreign Bodies
Penetrating Wounds

Identify the Pregnant Abdomen

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Initial Evaluation
Physical Exam
Auscultation
Confirm presence of bowel sounds
Free intraperitoneal air, blood, bowel contents = Ileus
However, injuries to adjacent structures may cause ileus
Ribs, pelvis, spine

Percussion
Pain with slight movt of ABD wall = peritonitis
Tympanic Sound = Free Air
Dull Sound = Hemoperitoneum
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Initial Evaluation
Physical Exam
Palpation
Guarding = involuntary muscle contraction
Sign of peritoneal irritation

Rebound Tenderness = Pain after rapid removal

Indicates established peritonitis from blood / GI contents

Gravid Uterus
Fundus @ Umbilicus = 20 week Gestation
Viable Fetus (in theory)

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Initial Evaluation
Physical Exam
Penetrating Wounds
Do not explore
Apply pressure to control bleeding

Impaled Objects
Do not remove
Stabilized object and transport

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Initial Evaluation
Physical Exam
Pelvic Stability
Compression of Iliac Crests
Movt or Bony Pain = Possible Fracture

Perineum
Blood @ Penile Meatus = Urethral Tear
Scrotal Hematoma = Pelvic Fracture

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Overview

Epidemiology
Anatomy
Initial Evaluation
Blunt Abdominal Trauma
Penetrating Abdominal Trauma
Pediatric Abdominal Trauma

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Blunt Abdominal Trauma

Most Commonly Injured Organs
1.
2.
3.
4.

Spleen
Liver
Small Intestine
Large Intestine

Two Primary Mechanisms

Compression
Deceleration
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Blunt Abdominal Trauma

Compression Injury
Result from direct blows or external compression
against a fixed object (lap belt, spinal column).
Subcapsular Hematomas to Solid Organs
Caused by small tears
Most common injury

Hollow Organ Rupture

Transient pressure = Intraluminal Pressure = Rupture

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Blunt Abdominal Trauma

Deceleration Injury
Result from a differential movement of fixed and
non-fixed parts of the body.
Tears occur @ Junction of Support Structures
Ligamentum Teres = Liver Laceration
Mesentery of Bowel = Mesenteric Tear
Retroperitoneum = Renal Artery Laceration

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Blunt Abdominal Trauma

Pre-Hospital Management
ABCs
IV Access
2 Large Bore peripheral IV (if possible)
Never delay transport for IV Access

IVF Crystalloid Resuscitation

Titrate Volume to Patients Clinical Response (VS)
Goal BP Mgt = SBP 90-100
Be Wary of Over Resuscitation = Hemodilution
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Blunt Abdominal Trauma

Pre-Hospital Management
Prolonged Transport Times & Hypotension
May be role for Pneumatic Anti-Shock Garments
Especially in case of Pelvic Fracture & Shock
RememberMore fluids may not be the answer
These Patients need definitive treatment at a Hospital
STOP THE BLEEDING
FILL THE TANKwith BLOOD

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Blunt Abdominal Trauma

Emergency Department Management
Initial Stabilization
Definitive Vascular Access
Central Lines

Continued Fluid Resuscitation

Crystalloid
Colloid (pRBCs)
Important here for EMS notification ED order O neg

Lucky Us!! Rectal Exam

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Blunt Abdominal Trauma

Emergency Department Management
Decision Tree
Unstable Pt.

OR

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Positive FAST
+ Hypotension

Neg. FAST
Stable

OR

CT A/P
Observe
69

Overview

Epidemiology
Anatomy
Initial Evaluation
Blunt Abdominal Trauma
Penetrating Abdominal Trauma
Pediatric Abdominal Trauma

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Penetrating Abdominal Trauma

Major Offenders
GSW
Stab Wounds
High mortality rate associated with abdominal GSW
& Stab due to Hemorrhage & Shock

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Penetrating Abdominal Trauma

Most Common HPI:
I was minding my own business when

Some Dude

Two Dudes

That *!#@!
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Shock Classification
Class I Hemorrhage (loss of 0-15%)
Minimal Tachycardia
No BP change

Class II Hemorrhage (loss of 15-30%)

Tachycardia
Delayed cap refill
Cool clammy skin
Anxiety
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Shock Classification
Class III Hemorrhage (loss of 30-40%)
Marked Tachycardia
Marked Tachypnea
Hypotension
Change Mental Status
Agitation &/or Anxiety

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Shock Classification
Class IV Hemorrahge (loss of >40%)
Marked Tachycardia
Marked Tachypnea
Hypotension
Narrow Pulse Pressure
Or immeasurable diastolic BP
Cold/Pale skin
Change in MS or Unconscious
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Shock Classification
Caveat:
Compensatory mechanisms prevent Hypotension
So look for Tachycardia

Patients on B-blockers will not be Tachycardic!!

Elderly patients may not Compensate well
ie. HR

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Penetrating Abdominal Trauma

GSW
Missile with high-energy transfer
Unpredictable extent of intra-abdominal injury
Missile track
Secondary missiles
Bullet fragments
Bone fragments

Stab Wounds
More predictable regarding injured organs
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Penetrating Abdominal Trauma

Pre-Hospital Management
ABCs
IV Access
2 Large Bore peripheral IV (if possible)
Never delay transport for IV Access

IVF Crystalloid Resuscitation

Titrate Volume to Patients Clinical Response (VS)
Goal BP Mgt = SBP 90-100

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Penetrating Abdominal Trauma

Pre-Hospital Management
Do not remove impaled objects or probe wounds
Patients should be delivered to Level I or next best
facility
As always, unstable patients should go to closest ED

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Wound Ballistics
Wound Ballistics
A very mystifying and often factitious specialty
Often entangles terms such as projectile-tissue
interactions and stopping power
Tough field to study, because not many people are
volunteering to be shot in the name of science

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Wound Ballistics
Simplest Convention
(for me)

Bullet Velocity

Popular Weaponry
Velocity to:
Penetrate Skin = 163 fps
Break Bone = 213 fps

9mm
.357 magnum
AK-47
M-16

= 1155 fps
= 1450 fps
= 2400 fps
= 3100 fps

** Other factors are important**

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Belkin, 1978

Overview

Epidemiology
Anatomy
Initial Evaluation
Blunt Abdominal Trauma
Penetrating Abdominal Trauma
Pediatric Abdominal Trauma

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Pediatric Abdominal Trauma

Epidemiology
Trauma is leading cause of Morbidity & Mortality in
pediatric population
Abdominal Trauma associated with 8.5% Mortality
rate
8-10% of all Trauma admissions in children

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Pediatric Abdominal Trauma

Pathophysiology
Unique Anatomy to Pediatric Patients

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Thinner musculature & padding = less protection

Ribs are more flexible = less dissipation of energy
Solid organs are comparatively larger than adult
Kidney more mobile = more commonly injured

84

Pediatric Abdominal Trauma

Frequency of Organ Injury
Liver
Spleen
Pancreas
Kidney
Stomach
Duodenum
Small bowel
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Blunt
15%
27%
2%
27%
1%
3%
6%

Penetrating
22%
9%
6%
9%
10%
4%
18%
85

Pediatric Abdominal Trauma

Duodenal Hematoma
Classic Case:
Kid falls off bike and strikes abdomen on end of
handlebarcomplaining continuing pain after

Duodenum
Located in mid-epigastric reagion
Fixed portion of bowel to retroperitoneum

Medical Issue
Hematoma can cause obstruction
Worst case = Hematoma leads to bowl wall necrosis
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Pediatric Abdominal Trauma

Spleen Rupture
Commonly Seen:
Blunt Trauma to LUQ/Flank
Football Players, Snowboarder/Skier

Why so High Risk?

Anatomic Position (with ribs overlaying)
Thin Capsule
Predisposition
Mononucleosis, Malaria, etc. lead to Splenomegaly
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Pediatric Abdominal Trauma

Spleen Rupture
Exam

Pain in LUQ
Left Shoulder Pain Kehrs Sign referred pain
Peritoneal Abdomen
Shock

Management
Fluid Resuscitation
OR vs. Embolization
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Pediatric Abdominal Trauma

Child Abuse
Occurs in All Socioeconomic Groups
Equal Gender Prevalence
Can occur at any age
The key is to have a high level of suspicion

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Pediatric Abdominal Trauma

Child Abuse
Non-accidental Trauma

Burn marks without splash marks

Wounds in various stages of healing
Whip marks
Suspicious Bruising

What to do?
Protect the Child
Do not allow an RMA
Alert RN / Physician staff of suspicion
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Presentation prepared basing on

following presentation:
Advanced Trauma Life Support Review By Don Hudson, D.O.,
FACEP/ACOEP Emergency Medicine Department Alaska
Regional Hospital
Abdominal Trauma by Brett Wiesley, MD

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91

Transfusion And Resuscitation

Guidelines

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92

Transfusion guidelines:
State goals for fluid replacement
Define conditions when blood and blood
products are appropriate
Must be followed unless the clinical situation
justifies deviations

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93

Blood products include:

Red blood cells:
Blood bank
Autologous (cell saver)
Whole blood
Fresh frozen plasma
Platelets
Fibrinogen concentrate/cryoprecipitate
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Managing Blood Loss Through

Transfusion
Always ask:
Is fluid resuscitation indicated?
Is the patient hemodynamically stable?

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Fluid Resuscitation Goals

Within the first 24 hours, fluids must be provided until
acidosisis under control:
Lactate <2.5 mmol/L or
Base deficit <2
Targets for blood tests:
Hemoglobin >8 and <10 g/dL
INR <1.5, PT <16 seconds, APTT <30 seconds
Fibrinogen >1 g/L
Platelets >50 x 109/L
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Hemodynamic Stability:
The 90 mmHg Cutoff
Patients are hemodynamically unstable if
SBP <90 mmHg or
Maintaining SBP >90 mmHg requires massive
fluids or vasopressor support
Patients are hemodynamically stable if
SBP >90 mmHg for 1 hour without these
measures
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RBC Use
Hypoperfusion indicators
Continued slow bleeding
Hgb
Urine Output
HR >120 w/ adequate analgesia
CI <3L/m2 + PCWP or CVP
SaO2 due to acute lung injury or altitude
Coronary or other organ ischemia syndromes
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Damage control

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The concept of damage control

Aims At rapid control Of hemorrhage
Appears to reduce patient mortality Limits
variability in RBC use Over first 24 Hours

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Damage Control: Staged Surgical

Repair
Stages of damage control:
Phase 1: Rapid transport, warming, bleeding control
Phase 2: Surgical control of hemorrhage and
contamination: pack and close temporarily
Phase 3: Resuscitation and stabilization
Phase 4: Definitive surgical repair
The goal is to achieve immediate control of lifethreatening hemorrhage, avoiding patient death
through exsanguination
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Physiologic Exhaustion

Low Core Temperature

Increased Base Deficit
Coagulopathy
Bowel Edema

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Goals Of Secondary Resuscitation

Correction of hypothermia (warm room, insulation,
internal or external active warming)
Correct Coagulopathy
Correct Acidosis and Optimize Hemodynamics
Ventilate
Assess for Missed Injuries
Identify Patients who may benefit from Surgical Reexploration
Initiating Specific Therapy to Reduce Complications
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Endpoints Of Secondary Resuscitation

Parameter Goal :
SvO2 > 65%
SaO2 > 95%
DO2I > 550 ml/min/m2
CI > 2,5-3 L/min
EDVI 80-120 ml/m2
Hct > 30-35%
Lactate < 2.5mg
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Reconstruction And Closure

Single Stage
Multiple Stage
Life
Neurosurgical Decompression
Failure of Hemorrhage Control
Function
Orthopedics
Cosmetic
Facial Fractures
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Strategies To Reduce Complications

Measurement of Intra Abdominal Pressure >30
mmHg confirms abdominal compartment
syndrome
Peptic Ulceration Prophylaxis
Thromboprophylaxis
Protective Lung Ventilation
Infection Control
Early Nutritional Support
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Ventilator Protocol and

Lung Protection Strategy

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Respiratory problems
SIGNS OF INTOLERANCE: Any of the following:
SaO2 90% or PaO2 <60 mmHg at oxygen
supplementation
Respiratory rate >35 breaths per minute
Respiratory distress (defined as marked use of
accessory muscles or paradoxical breathing)

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Respiratory Distress vs. Respiratory Failure

Distress

Failure

-Increased work of breathing

-Increased work of breathing

-Relative hypoxia/hypercapnea -Profound hypoxia/hypercapnea

-Compensating

-Decompensating - leading to
respiratory arrest

Its a constant reassessment process

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Goals Of Ventilator Management And

Weaning Guidelines
1. Ensure low tidal volumes (Vt) are used:
Limiting ventilation volumes (Vt) to 6 2 mL/kg PBW
2. Provide a lung-protective strategy for all ventilated patients:
Limiting plateau airway pressures to 30 cm H2O whenever
possible
3. Provide guidelines for the use of positive end-expiratory
pressure (PEEP):
Decreasing PEEP and FiO2 as early as possible given
oxygenation guidelines to move to spontaneous breathing trial
(SBT) as soonas possible

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Goals Of Ventilator Management And

Weaning Guidelines
4. Ensure extubation or discontinuation of
mechanical ventilation at earliest possible time:
Attempting to wean on an ongoing basis, at
least once daily when weaning criteria met
5. Avoid the use of muscle relaxants, except
where specifically indicated.

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Predicted Body Weight

PBW calculated as follows:
For males: PBW (kg) = 50 + .91 [height (cm)
152.4]
For females: PBW (kg) = 45.5 + .91 [height (cm)
152.4]

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Initiating Ventilator Procedures:

Oxygenation goal:
PaO2 5580 mmHg or
SpO2 8895%
PEEP:
Must be <35 cm H2O
Percent O2/PEEP ratio should be = 51
Example: FiO2 0.50; PEEP 12 (50/12 = 4.1)
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Continuing Ventilator Management:

pH Guidelines
Adjust for pH goal 7.257.45 (if possible):
Use resp rate (RR) if possible (35/min):
Keep PaCO2 25 mmHg
Bicarb infusion can be given at discretion of
bedside physician
If pH 7.15, then Vt can be increased by 1
mL/kg to achieve pH >7.15, and target plateau
pressure (Pplat) may be exceeded
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Presentation prepared basing on

presentations:
Dr Gordon Bernard Professor Medicine,
Allergy/Pulmonary and Critical Care, Medicine
Vanderbilt University School of Medicine
Dr Michael Parr, Intensive Care Unit, Liverpool
Hospital, Sydney, Australia
Dr John A. Morris Jr Professor of Surgery Vanderbilt
Coordinating Center, Nashville, Tennessee, USA
Professor Bertil Bouillon Campus Cologne Merheim,
University Witten/Herdecke, Germany
Novo Nordisk Control Clinical Trial materials

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