Trauma (main): Difference between revisions
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==Management==
==Management==
*[[Massive transfusion protocol]]


2 L of isotonic saline is the choice of fluid resuscitation in hemorrhagic shock through short and large gauge, preferably 16 or larger peripheral IVs. Occasionally it is impossible to obtain peripheral IV access and therefore you must place a central venous catheter.
==Complications==
Very commonly blood products are immediately available in severe hemorrhagic emergency cases and physicians forego normal saline for blood products.  Please note that infusing large volumes of NS can lead to development of a nonunion gap hyperchloremic metabolic acidosis, or metabolic alkalosis if one uses large amount of lactated ringers.
*[[Hypothermia]]
It is critical to keep monitoring the patient and their vitals, including the MAP (mean arterial pressure), which ideally you want to keep around 65 mmHg or their systolic blood pressure at around 90 mmHg.
*[[Acidosis]]
When a traumatic patient presents with severe hemorrhage, there is a fine line between overloading the patient with fluids, which can actually cause the patient to bleed out faster while diluting the blood products of the patient, therefore leading to catastrophic result.  The patients with severe and ongoing hemorrhage that can’t be controlled adequately or in timely manner, it is imperative to start immediate transfusion of blood products in a 1:1:1 ration of PRBCs (packed red blood cells), FFP (fresh frozen plasma) and platelets.
*(Dilutional) coagulopathy  
 
*[[Hypocalcemia]]
Complications:  during resuscitation of severe traumatic patients, the development of hypothermia (core temperature under 35 degrees Celsius) , acidosis, and coagulopathy, known as the lethal triad can have devastating and lethal consequences.
The coagulation system consists of complex enzymatic reactions that are temperature and pH dependent that result in the formation of blood clots to stop both the internal and the external hemorrhage.
A healthy individual maintains a physiologically normal pH of 7.35 to 3.45 through a complex and intricate balance of hydrogen ions and buffers that are predominately controlled by the pulmonary and renal systems.  Acidosis is defined as arterial pH under 7.35.  As a trauma patient’s perfusion worsens, they have a rapid accumulation of lactic acid in the tissues, therefore resulting in severe metabolic acidosis.  With severe academia (pH under 7.20), the consequences are detrimental and for the trauma patient, one of the most harmful effects is that their coagulation system can become severely impaired therefore leading to death.
Dilutional coagulopathy occurs when resuscitation of a bleeding trauma patient is with fluid (NS or PRBCS) or blood products that do not contain the same clotting factors lost in the acutely hemorrhaged whole blood.  Furthermore, in the critically injured patient, via complex series of enzymatic reactions, the clotting cascade can also become abnormally activated, therefore causing excessive clot formation and subsequent fibrinolysis out of proportion to the injury.  This excessive and abnormal activated of the coagulation system rapidly consumes the body’s remaining clotting factors, resulting in a further deficiency of the essential factors required to achieve hemorrhage control.
 
Another complication can occur after resuscitating trauma patients with blood products, which is hypocalcemia.  Hypocalcemia occurs because of the anticoagulant citrate.  Citrate binds with free calcium, therefore decreasing active calcium levels in the serum, leading to hypocalcemia.


==Disposition==
==Disposition==

Revision as of 23:06, 25 August 2016

This page lists the major trauma types. See fractures for ortho related injuries.

Background

Initial evaluation objectives

  1. Rapidly identify life-threatening injuries
  2. Initiate supportive therapy
  3. Organize definitive therapy

Locations of Possible Life-Threatening Bleeding

Lethal Triad of Major Trauma

  1. Hypothermia
  2. Coagulopathy
  3. Acidosis

Clinical Features

Classes of hemorrhagic shock[1]

Class I II III IV
Approximate blood loss <15% 15-30% 30-40% >40%
Heart rate ↔ ↔/↑ ↑ ↑↑
Blood pressure ↔ ↔ ↔/↓ ↓
Pulse Pressure (mmHg) ↔ ↓ ↓ ↓
Respiratory Rate (per min) ↔ ↔ ↔/↑ ↑
Urine Output (mL/hr) ↔ ↔ ↓ ↓↓
Glasgow coma scale score ↔ ↔ ↓ ↓
Base deficit^ 0 to -2 mEq/L -2 to -6 mEq/L -6 to -10 mEq/L -10 or less mEq/L
Need for blood products Monitor Possible Yes Massive transfusion protocol

^Base excess is the quantity of base (HCO3-, in mEq/L) that is above or below the normal range in the body. A negative number is called a base deficit and indicates metabolic acidosis.

Differential Diagnosis

Evaluation

  • Consider FAST
  • Consider CT

Management

Complications

Disposition

See Also

External Links

References

  1. ↑ American College of Surgeons Committee on Trauma. Shock: in Advanced Trauma Life Support: Student Course Manual, ed 10. 2018. Ch 3:62-81
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