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Initial Care of the Severely Injured Patient

Initial Care of the Severely Injured Patient
N Engl J Med 2019; 380:763-770
DOI: 10.1056/NEJMra1609326

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Initial Care of the Severely Injured Patient

  1. 1. Initial Care of the Severely Injured Patient N Engl J Med 2019; 380:763-770 DOI: 10.1056/NEJMra1609326
  2. 2. d “He who would become a surgeon should join an army and follow it.” - Hippocrates 460 – 370 BC.
  3. 3. MANAGEMENT OF SEVERE SEPSISApproach to the Care of Severe Injury Tourniquet Tranexamic Acid Permissive Hypotension Damage-Control Surgery The Golden Hour High-Ratio Massive Transfusion Ultrasonography REBOA
  4. 4. Tourniquet
  5. 5. Use field tourniquets for life-threatening extremity hemorrhage resulted in a demonstrable reduction in deaths from extremity exsanguination Advanced topical hemostatic dressings were also introduced to control limb and junctional exsanguination.
  6. 6. Tactical Combat Casualty Care Guidelines 31 JAN 2017
  7. 7. Use one or more CoTCCC-recommended limb tourniquets if necessary. Use a CoTCCC approved hemostatic dressing for compressible hemorrhage not amenable to limb tourniquet use. If the first tourniquet does not control bleeding after tightening, then add a second tourniquet side-by-side with the first.
  8. 8. Convert Limb tourniquets and junctional tourniquets if the following three criteria are met: – The casualty is not in shock. – It is possible to monitor the wound closely for bleeding. – The tourniquet is not being used to control bleeding from an amputation. Convert tourniquets in less than 2 hours if bleeding can be controlled with other means. Expose and use an indelible marker to clearly mark all tourniquet sites with the time of tourniquet application, reapplication, conversion, or removal.
  9. 9. Tranexamic Acid (Anti-fibrinolysis)
  10. 10. Tranexamic Acid 1 g administered as an IV bolus over 10 minutes, followed by a 1-g IV infusion over 8 hours, with the first dose given within 3 hours after injury.
  11. 11. Time-sensitive As early as possible after injury Incorporated into massive-transfusion programs
  12. 12. TXA safely reduced the risk of death in bleeding trauma patients in this study. On the basis of these results, TXA should be considered for use in bleeding trauma patients.
  13. 13. TXA reduces death due to bleeding in women with PPH with no adverse effects.
  14. 14. When used as a treatment for PPH, TXA should be given as soon as possible after bleeding onset.
  15. 15. Permissive Hypotension
  16. 16. “Inaccessible or uncontrolled sources of blood loss should not be treated with intravenous fluids until the time of surgical control.” - Walter Cannon 1871 – 1945
  17. 17. The common practice of administering 2 L of crystalloid fluid in hypotensive trauma patients worsens coagulopathy and acidosis and should be abandoned.
  18. 18. Normotensive patients should receive no fluid resuscitation Hypotensive patients should have fluid resuscitation withheld until SBP approaches 80 mmHg, small-volume boluses of blood or plasma (250 to 500 ml) should be given to maintain SBP between 80 and 90 mmHg. Traumatic brain injury
  19. 19. Damage-Control Surgery
  20. 20. Damage-control surgery is a technical strategy to control massive bleeding. “Staged” surgery Definitive surgery Between surgical stages, patients are placed in the ICU, where their physiological status is carefully managed, with attention to resuscitation, resolution of acidosis, maintenance of normothermia, and elimination of coagulopathy.
  21. 21. The Golden Hour
  22. 22. The primary purpose of the golden hour concept is to drive all efforts toward early hemorrhage control, including initial care, triage, rapid evacuation, and resuscitation. Focus on surgical hemorrhage control.
  23. 23. High-Ratio Massive Transfusion
  24. 24. Whole blood Component therapy Massive-transfusion protocol: high ratio of pRBC to FFP (1:1)
  25. 25. Blood products should be administered at as high a rate as possible (often as fast as 500 ml per minute) in order to obey the principles of hypotensive resuscitation, with a target SBP of 80 mmHg during damage-control surgery. Resuscitation is not a substitute for hemorrhage control. If resuscitation is initiated, the damage-control surgical interventions should be initiated simultaneously.
  26. 26. Ultrasonography (FAST)
  27. 27. REBOA Resuscitative Endovascular Balloon Occlusion of the Aorta
  28. 28. To control non-compressible, intra- cavitary hemorrhage below the diaphragm. Less invasive alternative to emergency thoracotomy and aortic cross-clamping for a patient who is hemodynamically compromised but does not have evidence of thoracic hemorrhage and is not in arrest.
  29. 29. Zone I: temporarily control infra-diaphragmatic hemorrhage in the absence of supra-diaphragmatic hemorrhage. Zone III: temporarily control massive pelvic or junctional hemorrhage in the absence of supra-diaphragmatic and intra-abdominal hemorrhage.
  30. 30. Abdominal visceral ischemia limits the occlusion time to less than 30 minutes, but ideally, the occlusion time should be as short as possible. The dangers of REBOA include total visceral ischemia, lower-limb loss, exacerbation of traumatic brain injury, spinal cord ischemia, and rapid proximal blood loss.
  31. 31. Brenner M, et al. Trauma Surg Acute Care Open 2018;3:1–3. doi:10.1136/tsaco-2017-000154
  32. 32. Indications for REBOA Guidelines for REBOA use and implementation Transfer of patients Management of the patient with REBOA
  33. 33. MANAGEMENT OF SEVERE SEPSISApproach to the Care of Severe Injury Tourniquet Tranexamic Acid Permissive Hypotension Damage-Control Surgery The Golden Hour High-Ratio Massive Transfusion Ultrasonography REBOA
  34. 34. Q & A

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