Chapter 32-Multiple Trauma

Question 1

List 5 anatomic differences for pediatric patients that should be considered in multi truama

Answer 1

1. Worse head injuries
   -Head to body ratio is greater
   -brain is less myelinated
   -cranial bones are thinner
2. Internal organs more susceptible to injury
   -more anterior placement of liver and spleen
   -thin abdominal musculature
   -less subcutaneous tissue mass
3. Kidneys more susceptible to deceleration injury
   - less protected by rib cage and more mobile
4. More susceptible t pulmonary injury
   -chest wall more elastic
5. Salter harris type #s
   -growth plates not closed yet
6. Spinal cord injuries (SCIWORA)
   -less blood supply to spinal cord
   -greater elasticity of spinal column

Question 2

What are the nexus criteria for CSPINE injury?

Answer 2

1. No posterior cervical midline tenderness
2. No evidence of intoxication
3. Normal level of alertness
4. No FND
5. No painful distracting injuries

If all criteria met, do not need imaging to clear CSPINE

Question 3

What are the criteria for obtaining CT chest in patients with blunt force trauma?

Answer 3

1. Age >60
2. rapid deceleration mechanism
3. Chest pain
4. drug or etoh intoxication
5. Abnormal alertness or mental status
6. Distracting painful injury
7. Tenderness to chest wall palpation

Question 4

Box 32.1 List 6 indications for a trauma surgeon to be present in the resuscitation bay within 15 min of patient arrival

Answer 4

1. Confirmed hypotension (SBP <90)
2. GSW wound or penetrating GSW to neck, chest, abdomen or extremities
3. Intubated patients
4. Respiratory compromise requiring intubation
5. GCS <8 attributed to trauma
6. At the discretion of ERP

Question 5

What are the goals of care for the trauma pt in the pre-hospital setting?

Answer 5

1. Trauma triage
2. Immediate intervention of life threatening injuries
3. Prevention of additional injury
4. Rapid transport to designated trauma centres
5. Advance notification to hospital

Question 6

What is the recommended threshold for PaO2 in brain trauma?

Answer 6

60 mm hg

Question 7

What is a chance fracture?

What is the mechanism of injury?

Answer 7

MOI- MVC Lap belt injury

Chance #- flexion-distraction injury within thoracic/ lumbar spine.

Associated with GI injury

Question 8

What is ‘Waddels triad’?

Answer 8

High speed Pedestrian vs MVC

1. Tibia/fibula or femur #
2. Truncal injuries
3. Craniofacial injuries

Question 9

List 4 mechanisms of GSW injury

Answer 9

1. Direct laceration
2. Crush Injury
3. Shock waves
4. Cavitation

Question 10

What are the 4 phases of ATLS?

Answer 10

1. Primary survey with intervention - includes efast
2. Consider transfer
3. Secondary survey and adjuncts
4. Monitor and disposition

Question 11

List 5 causes of hypotension in the acute trauma patient

Answer 11

Hemorrhage
tension pnx
traumatic pnx
hemo pnx
cardiac tamponade
neurogenic
acute MI
severe myocardial contusion
pre-exiting sepsis/ GI blood loss

Question 12

What are the inclusion criteria for applying the CT head rule? (3)

Answer 12

1. Minor head injury
2. GCS >13
3. Injury within 24hr

Question 13

What are the exclusion criteria for applying the CT head rule?

Answer 13

1. Age <16
2. Pregnant
3. Anticoagulated
4. > 24 hr after injury
5. NO trauma
6. Neuro deficits
7. Seizure prior to ED

Question 14

What are the high risk criteria for the CT head rule?

Answer 14

1. GCS <15 @2 hr post injury
2. Suspected open or depressed skull #
3. Any sign of basal skull fracture
4. Vomiting >2 episodes
5. Age >65 years

Question 15

What are the medium risk criteria for CT head rule (2)

Answer 15

6. amnesia before impact > 30 min
7. Dangerous mechanism

Question 16

What are considered ‘dangerous mechanisms’ with the CT head rule?

Answer 16

-pedestrian struck by vehicle
-occupant ejected from motor vehicle
-fall from elevation >3 feet or 5 stairs

Question 17

What are signs of basilar skull #

Answer 17

Hemotympanum
raccoon eyes
CSF/ rhinorrhea
battle sign

Question 18

What are the exclusion criteria for the Canadian CSPINE rules

Answer 18

1. non trauma cases
2. GCS <15
3. Unstable vital signs
4. Age <16 yo
5. Acute paralysis
6. Known vertebral disease
7. Previous cspine surgery

Question 19

According to the canadian cspine rules, what are the 3 high risk factors that mandate radiography?

Answer 19

Age >65
dangerous mechanism
paresthesias in extremities

Question 20

According the canadian cspine rules, what are considered low risk factors that allow for ROM assessment prior to imaging?

Answer 20

Simple rear end MVC
Sitting position in ED
Ambulatory at any time
delayed onset of neck pain
No midline cspine tenderness

Question 21

What is the sensitivity and specificity of the canadian cspine rule

Answer 21

Sensitivity 100%
Specificity 42%

Question 22

List 5 indications for CT abdo/pelvis imaging in blunt force trauma ?

Answer 22

Abdominal tenderness
significant mechanism of injury
abnormal efast
gross hematuria
seat belt sign

Question 23

What are the 7 Ts of MHP?

Answer 23

Trigger
Team
Testing
TXA
Temperature
Target
Termination

Question 24

What is the RABT score?

Answer 24

The Revised Assessment of Bleeding and Transfusion (RABT) Score – 1 point each

1. Shock index >1.0
2. Pelvic #
3. Positive efast
4. Penetrating injury

A 2018 study showed that RABT score ≥ 2 performed better than ABC score in predicting need for MHP.

Question 25

What is the recommended ratio of blood products in MHP according to the PROPPR trial?

Answer 25

2:1:1 (PRBC/plasma/PLT)

Question 26

What was the primary outcome of the PROPPR trial?

Answer 26

the PROPPR trial found that among patients with severe trauma and major bleeding there was no significant difference in 24hr or 30 day mortality in patients who received a 1:1:1 ratio compared to a 2:1:1 ratio, and because of practical considerations that allow faster administration of blood products using the 2:1:1 ratio. They therefore recommend: The first case of blood products should contain 4 units uncrossmatched pRBCs, be at the bedside in under 10 minutes, and IV running via rapid transfuser shortly thereafter Then the next case of blood products contains 4 RBC and 4 plasma (FFP) which should run simultaneously

Question 27

What is the the threshold for replacing fibrinogen?

Answer 27

Guidelines recommend a fibrinogen threshold for transfusion of fibrinogen or cryoprecipitate of <1.5-2.0 g/L.

Question 28

What blood tests need to be ordered in MHP?

Answer 28

Initial baseline tests: CBC coags (INR, PTT, fibrinogen) electrolytes (including calcium) VBG lactate +/- BhCG Q1h tests: Hgb, INR, lactate, VBG, fibrinogen

Question 29

Which electrolyte needs to be monitored and replaced in MHP?

Answer 29

Calcium The citrate preservative in blood products binds to serum calcium making it inactive. It is thus vital to monitor serum calcium and to consider administering calcium every 3 to 4 blood products that are administered.

Question 30

Based on the CRASH2 trial- What are indications for TXA administration in trauma patients?

Answer 30

1. TXA for all trauma patients in whom you suspect life-threatening hemorrhage within 3 hours of the time of injury 2. Trauma patients who are receiving blood products for hemorrhaging 3.Patients with initial SBP<90 or HR >110 based on the CRASH-2 trial. Give TXA ASAP – observational data suggests that every 15 min delay decreases its mortality benefit by 10%. For isolated head injured patients the CRASH-3 trial did not show a clinically significant benefit for early administration of TXA.

Question 31

What was the primary outcome of the CRASH-2 trial

Answer 31

early administration of TXA to bleeding trauma patients significantly reduced death due to bleeding. Specifically, treatment within 3 hours of injury was associated with a reduced risk of death. However, treatment after 3 hours appeared to increase the risk of death

Question 32

What is the dosing of TXA in the bleeding trauma patient?

Answer 32

1g TXA IV over 10 min then 1g infusion over 8 hr Some data to suggest 2gIV up front because 1g infusion often not done, ensures patient is adequately covered (EM Cases)

Question 33

What are relative contraindications for giving TXA?

Answer 33

1. History of coronary stent(s) 2. Active hematuria (it is thought that administration of TXA in the patient with hematuria may cause clot formation resulting in obstructive uropathy) 3. History of venous thromboembolic disease

Question 34

Define MHP

Answer 34

○ Replacement of patient's entire blood volume within 24 hours ○ Transfusion of > 4 PRBCs within 1 hour w/ ongoing losses ○ Transfusion of > 6 PRBCs within 1 bleeding episode with expectation for ongoing losses ○ > 50% of blood volume lost within 4 hours

Question 35

List 6 adverse events associated with MHP

Answer 35

-coagulopathy -thrombocytopenia -Hypothermia -Acidosis -Hyper K -Hypo Mg -Hypo Ca -L-shift on oxy Hb curve -Less deformable RBCs

Question 36

What are th

Question 37

What are the clinical targets during MHP? (6)

Answer 37

HR <100 MAP >55-75 GCS 15 U/O >30 ml/hr IVC w/ normal diameter and collapsibility

Question 38

What are the metabolic and hematologic parameters of MHP?

Answer 38

HGB 70-90 INR <1.8 Fibrinogen 1.5-2 PLT > 50 (>100 in head trauma) Metabolic: pH >7.3 Lactate <4 iCal >1.5

Question 39

When can MHP be terminated?

Answer 39

1. Normalizing hematologic and metabolic targets 2. Normalizing hemodynamic parameters

Question 40

What is the reversal treatment of massive hemorrhage on warfarin

Answer 40

FFP vitamin K prothrombin complex concentrate Factor VIIa **normalize INR ** both FFP at a minimum ratio of 1:2 and 2000 International Units (IU) PCC, along with vitamin K 10mg

Question 41

What is the reversal treatment of massive hemorrhage on anti platelets (ASA, Plaxix)?

Answer 41

Platelets

Question 42

What is the reversal treatment of massive hemorrhage on heparin

Answer 42

Protamine sulfate **monitor PTT

Question 43

What is the reversal treatment of massive hemorrhage on LMWH

Answer 43

Protamine sulfate

Question 44

What is the reversal treatment of massive hemorrhage on DOAC?

Answer 44

1. Dabigatran> Idarucizumab 5g 2. Xa inhibitor (eg., apixaban, rivaroxaban) > PCC 2000 IU;

Question 45

What special consideration should be made for pregnant patients in MHP?

Answer 45

pregnant and postpartum patients who are hemorrhaging tend to have low fibrinogen with an increased risk for DIC, so have a low threshold to give fibrinogen in the massively hemorrhaging obstetrical patient.

Question 46

When should MHP be triggered?

Answer 46

Clinical decision based on shock state shock index >1 delta shock index ≥0.1 RABT Score ≥2, resuscitation intensity) mechanism of injury Special populations (older, anticoagulants, certain drugs that alter vital signs)

Question 47

Describe the East recommendations for EDT

Answer 47

East EDT is strongly recommended for patients with penetrating thoracic injuries who present with a pulseless condition but also exhibit signs of life. Conditional: - Penetrating thoracic trauma + Pulseless without SOL - Penetrating extra thoracic injury + pulseless with or without SOL - blunt mechanism + pulseless WITH signs of life Recommend against: - pulseless without SOL after blunt injury

Question 48

Describe the East recommendations for EDT

Answer 48

Blunt trauma < 10 min of prehospital CPR Penetrating trauma : <15 min of prehospital CPR <5 min prehospital CPR if extra thoracic (neck or extremity) Other: pt is profound refractory shock

Question 49

What are considered 'sign of life' for East guidelines on EDT

Answer 49

pupillary response resp effort pulse motor activity electrical activity