shock and major haemorrhage Flashcards
what is the massive haemorrhage protocol in your trust?
Pack 1
this is to increase blood volume and restore blood pressure
- 6 units RBC
- 4 units FFP
Pack 2
this is to provide whole blood and restore physiology
- 6 units RBC
- 4 units FFP
- 1 Platelets
- 2 cryoprepitate
what is a belmont rapid transfuser used for?
- major haemorrhage protocol
- rapidly provides warmed blood (physiological temp) to patients
risks:
- venous air embolism
- infection
- hypothermia
advantages
- rapid infusion of large volumes of blood - 10-1000ml/hr
what is the definition of major haemorrhage?
- loss of blood volume in 24hrs
- 50% bloods loss in 3hrs
- 150ml loss per hour
what parameters do you use to monitor the response to it?
- pH = acidosis is a sign of under resuscitation
- HR, BP
1) what is TEG
2) how does the thromboelastography plot works?
3) what is rotem?
TEG and ROTEM are both viscoelastic tests used to detect coagulopathy and guide transfusion.
- provide quicker results than coagulation tests
TEG
Non-invasive test to quantitatively measure the ability of whole blood to form a clot
- assesses coagulation throughout all phases of clot formation
- 30-60mins to process
ROTEM
-similar to TEG - pin moves instead of the cup
what is shock?
A state of cellular and tissue hypoxia due to either reduced oxygen delivery, inadequate oxygen utilisation or increased oxygen consumption
what types of shock are there?
- Spinal shock - A transient physiological state, characterised by a loss of reflexes and sensorimotor function below the injury level - end of shock when bulboreflex returns
- neurogenic shock - loss of sympathetic tone following a spinal cord injury leading to bradycardia and hypotension
- cardiogenic shock - heart is unable to generate sufficient cardiac output
- Septic shock - life threatening organ dysfunction due to a dysregulated response to sepsis - decreased SVR
- hypovolaemic shock - inadequate organ perfusion due to a loss of intravascular volume
Why do we use injury scoring systems? Can you name one?
scoring system based on either anatomical site or physiological parameters
New injury severity score
- based on abbreviated injury score 1(minor) to 6 (unsurvivable)
- combined squares of the 3 highest scores regardless of whether from the same body site
- better predictor of outcome
Uses for Injury scoring systems:
- guide treatment i.e. damage control/ early treatment
- triaging patients - to centre/ major events
- research
- evaluate trauma centres
ISS> 18 = major trauma - 10% risk of mortality
single score of 6 = 75 - fatal
What is the trimodal disribution of death in trauma?
There are three peaks for death following trauma
Immediate - 50%
- within first mins of sustaining injury
- massive blood loss or neurological injury
Early - 30%
- within hours of arrival to hospital
- shock, hypoxia or neurological injury
Late - 20%
- within days to weeks
- multi system organ failure and infection
What is the lethal triad
- acidosis -inadequate resuscitation
- hypothermia - stops clotting and enzymes
- coagulopathy
What did the CRASH2 trial show
randomised control trial
- adult patients at risk of death from significant bleeding within 8hrs of admission
- outcome - death in first 4 weeks
- tranexamic acid - 1g over 10min then transfusion over 8hrs
Findings:
- reduced death when given within first 3hrs
- 4% risk of death in TXA
- 6% risk with placebo
Tell me the GCS scoring system
Eyes
- 4 spontaneous
- 3 to voice
- 2 pain
- 1 none
Voice
- 5 orientated
- 4 confused
- 3 words
- 2 sounds
- 1 none
Motor
6 - obeys commands
5 - localises to pain
4 - normal flexion
3 - abnormal flexion
2 - extension posture
1 - none
- max score of 15
- minimum score of 3
- score of 8 or less needs ventilation
What is meant by early total care and damage control orthopaedics?
How do you decide?
Early appropriate care
- definitive surgery for axial injuries - femur, spine and pelvic, compartment syndrome and vascular injuries
- lowers complication rates and pulmonary complications e.g. ARDS
- stable patients
Damage control care
- temporising initial life and limb saving treatments e.g. EX-fix, plaster, splints and traction
- unstable patients unable to withstand a second hit
- treatment focuses on:
1. resuscitative surgery
2. restoration of physiology
3. delayed definitive surgery
How to decide which treatment?
type of treatment is based on the pathophysiology of major trauma and the concept of a second inflammatory hit at 2-4days
Early appropriate care (within 8hrs)
- ISS > 18
- ph > 7.25
- Lactate <4
- BE > -5.5
Damage control
- ISS > 40 or >20 for resp
- GCS = 8 or less
- hypothermia
- head injury
- lactate> 4
- pH <7.25
- BE < -5.5
What is the pathophysiology of ARDS?
Acute lung reaction to trauma or infection
- inflammation of the lungs leading to release of inflammatory mediators, accummulation of fluid within alveoli and impaired gaseous exchage
Treatment
- mechanical ventilation and management of underlying cause
Prognosis
- multi-organ failure and death in 3-40%
- increased risk of reduced lung function, poor QOL and cognitive impairment
clinical scenerio
- unstable pelvic fracture - APC- dislocated SI joint and displaced pubic symphysis
- haemodynamically unstable - tachycardia and hypotensive
- RTC
Initial management
* MTC
* ATLS
* follow boast guidance on pelvic fractures
* treatment of hypotension, pelvic binder, activate MHP and iv tranexamic acid within an hr
* check response to blood - lactate, ph - may need second pack
* check if open fracture - rectal
Imaging
* to identify cause of bleeding - don’t assume just pelvis
* CT - iv contrast - head, chest, abdomen and pelvis - with CT scanogram head to toe
Operative management
* Alert general surgeons, anaesthetics
* pelvic binder to remain on during laparotmy - only remove once stable
* ex-fix and pack if not
