Trauma: Stabilization and Transport

Trauma: Stabilization and Transport
Division of Critical Care Medicine
Children’s Healthcare of Atlanta
Atlanta, Georgia

Trauma:Stabilization and Transport
Objectives
* Discuss the epidemiology of pediatric trauma
* Review the primary survey
* Identify priorities in care
* Discuss differences between adult & pediatric trauma
* Discuss pediatric trauma management
* Review the development of and
guidelines for transport

Neurosurgeon
Resuscitation Team
Surgical Specialties
Medical Specialties
Nursing
ICU
OR
Anesthesia
Orthopedic Surgeon
Trauma Surgeon
ALWAYS OPEN TRAUMA CENTER

Trauma:Initial Stabilization
Trauma:Initial Stabilization
The Golden Hour
* R. Adams Cowley, MD
* Care within 60 min.
* mortality if care given > 60 min.
"You live or die depending on where you have your accident because they take you to the nearest hospital!"

R. Adams Cowley, MD
“In the Blink of an Eye”
A-M-P-L-E History

A - Allergies
M - Medications
P - Previous history
L - Last ate
E - Events of accident

Trauma:Initial Stabilization Management of Multiple Trauma
* Primary survey
* Initial stabilization
and resuscitation
* Secondary survey
* Definitive care

Trauma:Initial Stabilization The Primary Survey
* A rapid initial assessment
* An "ABC" approach
* Resuscitation done simultaneously

Trauma:Initial Stabilization The Secondary Survey
* After the "ABCs"
* Head to toe examination

Trauma Initial Stabilization Definitive Care Phase
* Overall management
* Fracture stabilization
* Stabilization/transport
* Emergent surgery

Trauma:Initial Stabilization Pediatric Considerations
* ABCs
* Differences:
1) Size
2) Injury pattern
3) Fluids
4) Surface area
5) Psychological
6) Long term effects

Trauma:Initial Stabilization
In pediatric trauma, you don’t just have and injured child, you have an injured family
M. Eichelberger, MD
“In the Blink of an Eye”
Trauma:Initial Stabilization The Primary Survey
A - Airway and C-Spine
B - Breathing
C - Circulation (with hemorrhage control)
D - Disability
E - Exposure

Trauma:Initial Stabilization The Primary Survey
* Airway:
o Establish patency
o Beware C- Spine
o Do not:
+ Flex
+ Hyperextend
* Oxygen
o treat potential hypoxemia
o all trauma patients get O2

Trauma:Initial Stabilization Pediatric Considerations
* Craniofacial disproportion
* "Sniffing" position
* Obligate nose breathers
* Anatomy
o tongue
o larynx
o trachea

Trauma:Initial Stabilization Suspected Airway Obstruction
* Stridor
* Cyanosis
* Absence of breath sounds
* Dysphagia, snoring, gurgling
* Altered mental status
* Trauma to head, face, neck

Trauma:Initial Stabilization Cervical Spine Differences
* Flexible interspinous ligaments
* Underdeveloped neck muscles
* Poorly developed articulations
* Anterior vertebral bodies
* Flat facet joints
* Large head to BSA

Trauma:Initial Stabilization Cervical Spine
* Predisposed to serious high cervical injuries
* Assume its presence in:
o Blunt injury above clavicle
o Multisystem trauma
o Significant injury - MVA, fall
o Altered sensorium

Trauma:Initial Stabilization Cervical Spine: Radiographs
* Pseudosubluxation
* distance dens and C-1
* Growth plate fracture
* SCIWORA

Trauma:Initial Stabilization Airway Management
* Clear airway
* Jaw thrust/stabilization maneuver
* Oral/nasal airway
* Oxygenate/ventilate
* Intubation
* Cricothyroidotomy

Trauma:Initial Stabilization C-Spine Immobilization
* Backboard
* Appropriate C-collar
* Snadbags or towel
* Tape
* Torso immobilization

Trauma:Initial Stabilization Primary Survey: Breathing
* Assess via
o Exposure
o Rate/depth of respiration
o Inspection/palpation
o Quality/symmetry of breath sounds

NB: An intact airway Does Not assure adequate ventilation!!

* Oxygen
* Assisted ventilation
* Alleviate life threatening injuries

Thoracic Injury Heart, Lung, Mediastinum
* Penetrating
o Sucking, Bubbling
o Hemopneumothorax
o Tamponade
* Blunt
o Flail Chest
o Contusion (lung, heart)
o Aortic Dissection
o Tracheal Rupture
o Diaphram Rupture

Trauma:Initial Stabilization Chest Trauma
* Tension pneumothorax
* Hemothorax
* Flail chest
* Cardiac tamponade

Trauma:Initial Stabilization Chest Trauma
* Blunt injury common
* More compliant chest wall
* Sensitive to flail segment
* Mobile mediastinum
* Major vascular injury uncommon

Trauma:Initial Stabilization Tension Pneumothorax
* Air in the pleural space without exit
* Collapse of ipsilateral lung
* Compressed contralateral lung
* Mediastinal shift

Trauma:Initial Stabilization Tension Pneumothorax: Signs and Symptoms
* Respiratory distress
* Unilaterally diminished breath sounds
* Hyperresonance on affected side
* Tracheal deviation
* Distended neck veins
* Cyanosis

Trauma:Initial Stabilization Tension Pneumothorax: Treatment
* Needle decompression
o 2nd intercostal space mid-clavicular line
* Chest tube
o 4-5th intercostal space mid-axillary line

Trauma:Initial Stabilization Hemothorax: Signs and Symptoms
* breath sounds on affected side
* Dullness to percussion
* Hypovolemia
* Flat vs distended neck veins

Trauma:Initial Stabilization Hemothorax: Treatment
* Fluids/blood
* Decompression
* Chest tube
* Autotransfusion

Trauma:Initial Stabilization Flail Chest
* Boney discontinuity of the chest wall
* Major problem = underlying injury
* Signs and symptoms
o respiratory distress
o paradoxical chest wall movement
o severe chest pain

Trauma:Initial Stabilization Flail Chest:Treatment
* Oxygen
* Stabilize segment
* Re-expand lung
* + intubation
* Give fluids cautiously

Trauma: Initial Stabilization abdominal trauma
* Following the head and extremities, the abdomen is the third most commonly injured anatomic region in children
* significant morbidity and may have a mortality rate as high as 8.5%
* abdomen is the most common site of initially unrecognized fatal injury in traumatized children

Trauma: Initial Stabilization abdominal trauma
* Why more prone to abdominal injury
o child has thinner musculature
o ribs are more flexible in the child
o solid organs are comparatively larger in the child
o fat content and more elastic attachments leading to increased mobility
o bladder is more exposed to a direct impact to the lower abdomen

Intraperitoneal Hemorrhage Management
o Immediate surgical exploration
o Non-operative protocols
+ successful in more than 95% of blunt abdominal trauma in appropriately selected cases

Intraperitoneal Hemorrhage
Immediate Surgical Exploration
o Abdominal distention + “shock”
o Transfusion requirement > 40 cc/kg
o Peritonitis
o Pneumoperitoneum
o Bladder rupture

Intraperitoneal Hemorrhage
CT Scan
o Hemodynamically stable
o Unreliable exam
o Immediate non-abdominal surgery
o Specific Indicators
Hematuria (any)
SGOT 200, SGPT > 100
Hyperamylasemia

Intraperitoneal Hemorrhage
* FAST
o standard part of the initial evaluation of bluntly injured abdomens in adults
o rapid assessment of the peritoneal cavity and can detect free fluid

Intraperitoneal Hemorrhage
o Pediatrics role of FAST is still up for debate
+ Detailed information regarding the grade of organ injury is not provided by the FAST
+ operator-dependent and lacks specificity
+ FAST examination produces a significant number of false-negative results

Intraperitoneal Hemorrhage
Diagnostic Peritoneal Lavage
Trauma:Initial Stabilization Circulation
Trauma:Initial Stabilization Frequent Reassessment of Vital Signs
What Are Normal Pediatric Vital Signs?
Trauma:Initial Stabilization Pediatric Vital Signs
Trauma:Initial Stabilization Circulation: Vital Signs
Trauma:Initial Stabilization Circulation: Shock
Trauma:Initial Stabilization Circulation: Fluid Therapy
Trauma:Initial Stabilization Circulation: Fluid Therapy
Trauma:Initial Stabilization Circulation: Blood Replacement
Trauma:Initial Stabilization Circulation:Pediatric Considerations
Trauma:Initial Stabilization Disability
Trauma:Initial Stabilization Disability: Children's Glasgow Coma Scale
Trauma:Initial Stabilization Pediatric Trauma Score
Airway Normal Oral or nasal Intubated, tracheostomy
Trauma:Initial Stabilization Expose: Pediatric Considerations
Trauma:Initial Stabilization Cathertization
Trauma:Initial Stabilization Definitive Care
Questions ??
References
Trauma: Stabilization and Transport .ppt

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Acute Mental Status Changes in the Intensive Care Unit

Acute Mental Status Changes in the Intensive Care Unit
By:Danagra Georgia Ikossi, MD
Stanford General Surgery Resident


* Brief review of Delirium, Seizures and Stroke
* “ICU Psychosis”
o How do you know if they’re confused? (J. Am. Ger. Soc. 2005)
o Why do they become delirious? (Critical Care 2001)
o Does delirium portend a poor outcome? (JAMA 2004)
o Geriatrics: Delirium plus dementia, what to do? (J. Am. Ger. Soc. 2005)


Disorders of Mentation
* Abnormalities of mental function
* Levels of Conciousness

Etiology of depressed level of consciousness
In non head injured patients
o SMASHED
o Substrate deficiencies (glucose, thiamine)
o Meningoencephalitis or Mental illness (malingering, psychogenic coma)
o Alcohol or Accident (CVA)
o Seizures
o Hyper-capnia, -glycemia, -thyroid, -thermia OR Hypo-xia, -tension, -thyroid, -thermia
o Electrolyte abnormalities (hyperNa, hypoNa, hyperCa) and Encephalopathies
o Drugs

Eye Opening
Spontaneous
To Speech
To Pain
Verbal Oriented
Inappropriate
Incomprehensible
Abnormal Extension
Abnormal Flexion
Withdraws
Localizes
Obeys Commands
Motor
Glascow Coma Scale: GCS
“T” denotes intubation
Predictive value of GCS
* Septic Encephalopahthy
Delirium
DSM-IV Diagnosis of Delirium
A. Reduced ability to maintain and shift attention to external stimuli
B. Disorganized thinking, as indicated by rambling, irrelevant, or incoherent speech
C. At least two of the following:

1. Reduced level of consciousness
2. Perceptual disturbances: misinterpretations, illusions, or hallucinations
3. Disturbance of sleep–wake cycle with insomnia or daytime sleepiness
4. Increased or decreased psychomotor activity
5. Disorientation to time, place, or person
6. Memory impairment

D. Abrupt onset of symptoms (hours to days), with daily fluctuation

E. Either one of the following:
1. Evidence from history, physical examination, or laboratory tests of specific organic etiologic factor(s)
2. Exclusion of non-organic mental disorders when no etiologic organic factor can be identified

Delirium
* Hypoactive delirium:
* Dementia and Delerium:
* Management
THIS IS MUCH MORE THAN WE USE
Important to differentiate Delirium from DTs
* Delirium Tremens
Cocaine Related Delirium
Who becomes delirious?

Delirium, Dementia or Both?
* Delirium is a risk factor for increased ICU and Hospital length of stay
* In the geriatric population, becomes difficult to differentiate between underlying dementia and delirium
* Group at Brown did a prospective study of 118 patients in ICU
* Baseline dementia diagnosis given by family on Blessed Dementia Scale
* Delirium diagnosed by CAM and CAM-ICU scales
CAM ICU SCORE
Overall CAM ICU Score:
Delirium and mortality
Perspective on ICU Psychosis
AACM and SCCM Guidelines
Seizures
* Second most common neurologic complication in ICU
* Movements
* Generalized Seizures
* Partial Seizures
* Status Epilepticus
New Onset Seizures
* Drug intoxication
(amphetamies, cocaine, phenocyclidine, cipro, imipenam, lidocaine, PCN, theophylline, TCA)
* Drug withdrawal (EtOH, BZO, Barbiturates, Opiates)
* Infection (Meningoencephalitis, abscess)
* Ischemia (focal or diffuse)
* Space occupying lesion (tumors or bleeds)
* Metabolic derrangement
(hepatic encephalopathy, uremia, hypo-glycemia, -natremia, -calcemia)

* Evaluation:
o Examination looking for lateralizing signs
o Review of medications
o Imaging (CT)
o Procedural diagnostics (LP, labs, blood cultures)
* Management:
o BZO
o Valium 0.2mg/kg IV stops 80% of seizures within 5 min, effect lasts 30 min
o Ativan 0.1mg/kg is as effective and lasts 12-24hrs
o Dilantin 20mg/kg following valium, aim for 20mg/l therapeutic serum level

Stroke
* Acute neurologic disorder
* Nontraumatic brain injury, vascular origin
* Focal findings (not global)
* Persists for more than 24 hours
* 80% ischemic, 20% of which are embolic
o Most thrombi are mural, LA, LV, DVT with PFO
* TIA: transient ischemic attack, focal deficits resolve in less than 24 hours (ischemia rather than infarction)
* Minor Stroke = RIND (reversible ischemic neurologic deficit) resolves within 3 weeks of event
* Major Stroke = deficits persist for more than 3 weeks
* Evaluation: common things you’ll see at the bedside
o Full neuro exam, looking for focal deficits
o Seixures in 10% of cases, focal and within first 24 hours
o Fever in 50% of strokes (not with TIA) – look for other sources
o Coma and LOC are not common – more likely hemorrhage, massive infarct with edema, brainstem infarction, seizure (absence) or postictal state
o Aphasia – Left MCA distribution
o Weakness in contralateral limbs (can also have other metabolic causes)

Diagnostic Studies
* Time is brain
* Coags, Chemistries: hypoglycemia, hyponatremia, ARF
* ECG: Afib?
* CT head: 70% sensitivity for infarct, 90% for hemorrhage - critical to distinguish btwn these
* Better if after 24 hours for infarct
* MRI: more sensitive esp for brainstem and cerebellar strokes
Diagnostics and Treatment
* ICP: monitoring not recommended routinely
o Elevate HOB 30 degrees
o Do not use measures that will decrease CBF
o minimize suctioning (HTN)
o Do not hyperventilate (reduces CBF)
o Steroids not recommended
o Hyperosmolar therapy can be used if edema is severe (Mannitol, HTS)

Acute Mental Status Changes in the Intensive Care Unit.ppt

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PEGylation

Mr. Sanju Patel a visitor of this blog asked me to post detail information on pegylation.

According to medical dictionary -
Oeginterferon alfa-2a,
a covalent conjugate of recombinant interferon alfa-2a and polyethylene glycol, used in the treatment of chronic infection by hepatitis C virus. It is administered subcutaneously. - Mosby's Medical Dictionary, 8th edition.

Pegasys
Pharmacologic class: Interferon
Therapeutic class: Biological response modifier
Pregnancy risk category C
FDA Boxed Warning

• Drug may cause or aggravate fatal or life-threatening neuropsychiatric, autoimmune, ischemic, and infectious disorders. Monitor patient closely with periodic clinical and laboratory evaluations. Withdraw drug in patients who have persistently severe or worsening signs or symptoms of these conditions. In most cases, these disorders resolve once therapy ends.
• Concurrent use with ribavirin may cause birth defects or fetal death. Use extreme care to avoid pregnancy in female patients and female partners of male patients.
Action

Unclear. Thought to bind to specific cell-surface receptors, suppressing cell proliferation and viral replication. Also increases effector protein levels and reduces white blood cell (WBC) and platelet counts.
Availability

Injection: 180-mcg/ml vial

⊘Indications and dosages

➣ Chronic hepatitis C virus infection

Adults: 180 mcg subcutaneously q week for 48 weeks. If poorly tolerated, reduce to 135 mcg weekly; some patients may need reduction to 90 mcg.
Dosage adjustment

• Neutrophil count less than 750 cells/mm3 or platelet count less than 50,000 cells/mm3
• Hepatic disease
• End-stage renal disease requiring dialysis
• Serious adverse reactions
Off-label uses

• Renal cell carcinoma
Contraindications

• Hypersensitivity to drug
• Autoimmune hepatitis
• Decompensated hepatic disease
• Infants and neonates (due to benzyl alcohol content)
Precautions

Use cautiously in:
• thyroid disorders; bone marrow depression; hepatic, renal, or cardiac disease; pancreatitis; autoimmune disorders; pulmonary disorders; colitis; ophthalmic disorders; depression
• elderly patients
• pregnant or breastfeeding patients
• children younger than age 18.
Administration

• Keep refrigerated. Before giving, roll vial between palms for 1 minute to warm; don't shake. Protect solution from light.
• Don't use if solution is cloudy or contains visible particles.
• Administer undiluted in abdomen or thigh by subcutaneous injection.
• Know that drug may be used alone or with ribavirin.

Adverse reactions

CNS: dizziness, vertigo, insomnia, fatigue, rigors, poor memory and concentration, asthenia, depression, irritability, anxiety, peripheral neuropathy, mood changes, suicidal ideation

CV: hypertension, chest pain, supraventricular arrhythmias, myocardial infarction

EENT: vision loss, blurred vision, retinal artery or vein thrombosis, retinal hemorrhage, optic neuritis, retinopathy, papilledema

GI: nausea, vomiting, diarrhea, abdominal pain, dry mouth, anorexia, GI tract bleeding, ulcerative and hemorrhagic colitis, pancreatitis

Hematologic: anemia, leukopenia, thrombocytopenia, neutropenia

Metabolic: diabetes mellitus, aggravated hypothyroidism or hyperthyroidism

Musculoskeletal: myalgia, back pain, joint pain

Respiratory: pneumonia, interstitial pneumonitis, bronchoconstriction, respiratory failure

Skin: alopecia, pruritus, diaphoresis, rash, dermatitis, dry skin, eczema

Other: weight loss, flulike symptoms, injection-site reaction, pain, autoimmune phenomena, severe and possibly fatal bacterial infections, severe hypersensitivity reactions including angioedema and anaphylaxis
Interactions

Drug-drug. Theophylline: increased theophylline blood level

Drug-diagnostic tests. Absolute neutrophil count, hematocrit, hemoglobin, platelets, WBCs: decreased values

Alanine aminotransferase: transient increase

Glucose, thyroid function tests: decreased or increased levels

Triglycerides: increased levels
Patient monitoring

Assess cardiac and pulmonary status closely. Watch for evidence of infections and hypersensitivity reactions, including anaphylaxis.
• Before therapy begins, assess CBC (including platelet count), blood glucose level, and thyroid, kidney, and liver function tests. Continue to monitor at 1, 2, 4, 6, and 8 weeks and then every 4 weeks during therapy (more often if abnormalities occur). Monitor thyroid function tests every 12 weeks.
Monitor for development of diabetes mellitus, hypothyroidism, and hyperthyroidism.
If serious adverse reaction occurs, discontinue drug or adjust dosage until reaction abates, as prescribed. If reaction persists or recurs despite adequate dosage adjustment, discontinue drug.
Patient teaching

• Teach patient or caregiver how to administer injection subcutaneously in thigh or abdomen and how to dispose of equipment properly, if appropriate.
Advise patient to promptly report rash, bleeding, bloody stools, infection symptoms (such as fever), decreased vision, chest pain, severe stomach or lower back pain, shortness of breath, depression, or suicidal thoughts.
• Instruct patient to administer drug exactly as prescribed. If he misses a dose but remembers it within 2 days, tell him to take missed dose as soon as possible; if more than 2 days have elapsed, tell him to contact prescriber.
• Caution patient not to switch brands without prescriber's approval.
• Instruct patient to have periodic eye exams.
• Advise female patient of childbearing age to avoid pregnancy and use two birth control methods before, during, and up to 6 months after therapy. Instruct male patient to use condoms.
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.

Nursing Spectrum Drug Handbook 2009. © 2009 by The McGraw-Hill Companies, Inc.

Interferons

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Current and Future Treatment of Chronic Hepatitis C

Treatment of Chronic Hepatitis C

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