12/17/13

Trauma: The First 15 Minutes

Elisa M. Mazzaferro, MS, DVM, PhD, DACVECC

Shelby
! 3 year old F(S) Beagle ! Nonambulatory after vehicular trauma ! No loss of consciousness ! No prior health problems

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Physical Examination
! ! ! ! ! Pale mm, prolonged CRT Mild epistaxis Tachycardic Clear lung sounds, eupneic Miotic pupils, sluggishly responsive to light ! Crepitus in left coxofemoral area ! Multiple skin abrasions

Problem List
! Miotic pupils ! Coxofemoral crepitus ! Tachycardia with pale mucous membranes ! Skin abrasions ! Epistaxis

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ABCs of Trauma
! ! ! ! Airway Breathing Circulation Disability

Oxygen Delivery
DO2 = Q x CaO2 Q = Heart Rate x Stroke Volume Preload Afterload Contractility

CaO2 = [1.34 x Hb x SaO2] + [0.003x PaO2]

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Fluids

Treatment to Improve Oxygen Delivery

DO2 = Q x CaO2
Inotropes

Antiarrhythmics

Q = Heart Rate x Stroke Volume

Crystalloids Colloids

Preload

Afterload

Contractility

CaO2 = [1.34 x Hb x SaO2] + [0.003x PaO2]

Whole Blood Packed RBCs Oxyglobin
Oxygen supplementation

Analgesia
Abrasion and Miosis = Head Trauma

! What about the head trauma? ! What analgesic should we give?

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Analgesia
! Always use judiciously

Dose Response Curve of Opioids

Fent

% Analgesia

Oxy

Mor

Torb Bup

DOSE

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Analgesics

Circulation Fluid Therapy

!Large (shock) bolus dosing of crystalloid, hypertonic or colloid fluids can raise pressures to supernormal levels !Newly formed clots to break off damaged vessels !Dilutional coagulopathy

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Fluid Resuscitation During Shock

! First identify underlying possible complicating factors:
! Closed cavity hemorrhage ! Pulmonary contusions ! Head/brain trauma ! Cardiac dysfunction

Phases of Fluid Administration

! Emergency phase ! Rehydration phase ! Maintenance phase

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Early Compensatory Shock

! 15 30% loss of circulation volume
! Hyperemic mucous membranes ! Tachycardia ! Vasoconstriction ! Rapid CRT ! Normal to increased mean arterial pressure

Early Decompensatory Shock

!30 40% loss of circulating volume
! Pale mucous membranes ! Tachycardia ! Prolonged CRT ! Normal to decreased mean arterial pressure

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Late Decompensatory Shock

! > 40% loss of circulating volume
! Pale to grey mucous membranes ! Prolonged CRT ! Normal to decreased heart rate ! Decreased mean arterial pressure ! Poor pulse quality ! Hypothermia

Over-treatment
! Pulmonary contusions worsen with overzealous fluid therapy ! Large volumes quickly can increase fluid loss into damaged tissues ! Iatrogenic interstitial fluid overload worsens hypoxemia and oxygen delivery ! Iatrogenic dilutional coagulopathy

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Rapid Volume Resuscitation

! IV or IO are the only ways to go
! SQ fluids not appropriate for volume replacement in an animal in shock

! Be prepared to infuse one whole blood volume per hour if a healthy vasculature is present
! 90 mls/kg/hour for dogs ! 40-45 mls/kg/hour for cats

Rapid Volume Resuscitation

! Be prepared to infuse one whole blood volume per hour if a healthy vasculature is present !90 mls/kg/hour for dogs !40 to 45 mls/kg/hour for cats

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Rapid Volume Resuscitation

! Start with ! of the calculated shock dose, then reassess perfusion parameters !Heart rate !Blood pressure !Capillary refill time !Urine output

Rapid Volume Resuscitation

! Helpful Hint !For dogs, take their body weight in POUNDS, and add a zero !This equals ! shock dose of fluids!

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Small Volume Resuscitation

! Colloidal administration 5 ml/ kg bolus ! Reassessment of perfusion parameters ! Used in: !Head trauma or closed cavity hemorrhage !Pulmonary contusions

Hypotensive Resuscitation
! Limited volume !Conservative volumes to control hemorrhage !Permissive hypotension ! Delayed resuscitation !No volume resuscitation until hemorrhage controlled

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Hypertonic Saline (7.5% NaCl)

! 3 5 ml/kg IV over 10 15 minutes ! Synergistic with Dextran-70 ! Effects last 30 minutes ! Improved cerebral perfusion

Pneumothorax Treatment
! Thoracocentesis !Diagnosis and treatment ! Thoracostomy tube !Continuous production ! Multiple thoracocentesis

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Thoracocentesis Supplies
! Antimicrobial scrub ! Clippers/ blades ! 60 ml syringe ! 3-way stopcock ! Extension tubing ! Red/purple topped tubes ! 22 g needles

Thoracocentesis

Clip a 10 cm square area in the middle of the thorax.

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Thoracocentesis

Palpate the intercostal space in the middle of the clipped area. Insert the needle.

Thoracocentesis

As soon as the needle enters the pleural space, place the needle parallel with the body wall, to avoid iatrogenic lung laceration. Make sure that the bevel of the needle is directed inwards.

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Thoracocentesis

Have an assistant draw off any air or fluid that is present.

Respiratory Injury
! ! ! ! ! 57% of dogs with multiple trauma Pulmonary contusions Pneumothorax Fractured ribs Diaphragmatic hernia

Spackman CJA, et. al. JAVMA 1984

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Pulmonary Contusions
! Complication of blunt chest trauma ! Under wounds, rib fractures or without obvious external injury ! Alveoli fill with blood and fluid !Intrapulmonary shunt !Hypoxemia

Pulmonary Contusions
! Interstitial to alveolar lung pattern

! May not be evident on early radiographs

! Radiographic changes may continue to develop for 2 to 24 hours

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Anything Else?

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Abdominocentesis
! Clippers and blades ! Antimicrobial scrub ! 20 22 gauge needles ! 3 ml syringe ! Red and purple topped tubes ! Culturettes

Other Diagnostics

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What Should We Do With This?

Making a Diagnosis of Uroabdomen

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Making a Diagnosis of Uroabdomen

Other Diagnostics
! SpO2 = 87% on room air

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Oxyhemoglobin Dissociation PO SO Curve

a 2 p 2 100 90 80 70

100 80 70 60 50 40 30 20 10
10 20 30 40 50 60 70 80 90 100

97.5 96.5 92.5 89 83.5 75 57 35 13.5

SpO2

60 50 40 30 20 10

PaO2 in mm Hg

What About Supplemental Oxygen?

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Other Diagnostics
! SpO2 later worsened to 80% on 40% nasal oxygen ! Nasopharyngeal Oxygen

What Else Can We Do?

! Other

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Neurologic Status

When Should We Fix Her Leg?

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How Do You Want To Anesthetize Her?

Epidural

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Doses
! Duramorph: 0.1mg/kg ! Bupivacaine (0.5%):
K-9 1cc/4.5kg Feline 1cc/7kg

! Dilution 0.33ml/kg 6ml total

Post-Op
! ! ! ! Fentanyl IV CRI 3 7 mcg/kg/hour Urinary catheter Rimadyl 2.2 mg/kg PO BID ! Transitioned to Tramadol 24 hours post-op, then home

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