14/02/15

Decision  Making  in  Trauma

v Most important decisions involving trauma cases are

not about whether to intervene but when to intervene

What’s  Broken?  Approach  to  the  Motor  

Vehicle  Accident  Patient

v  Daniel L. Chan, DVM, DACVECC, DECVECC, DACVN, MRCVS

v  Section of Emergency and Critical Care

Deciding  When  to  Intervene Major  Body  Systems  Assessment

v Patient must tolerate your interventions which may
involve restraint, sedation or anaesthesia
v Stabilisation of Major Body Systems first!
Ø These are the body systems which are immediately life-
threatening if compromised
Ø Whatever the underlying cause, all patients will ultimately
die due to failure of one of the major body systems
Ø Its always “Heart, Brain, Lungs”

Major  Body  Systems  Assessment “Dexter”

v 6 yr old MN NorfolkTerrier

Ø Cardiovascular system v Vehicular trauma
v Dog was witnessed to walk
Ø Neurological system after accident
Ø Respiratory system

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“Dexter” Major  Body  System  Assessment

v Presented laterally v HR 110 bpm

recumbent v No murmurs
v Conscious v No arrhythmias
v Not in any distress v Tall narrow pulses
v RR 38 bpm
v Very harsh lung sounds

Major  Body  System  Assessment What  do  you  want  to  do?

v Dull, poorly responsive

v Normal pupillary light reflex
v Normal pupil size
v Paraparetic
v Evidence of head injury

What  do  you  want  to  do? What  do  we  know  so  far…

v Give fluids? v Dog with blunt trauma

v Cardiovascular system compromised
v Give steroids? v Neurological system compromised
v Respiratory system compromised
v Do more diagnostics?

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Some  additional  information What  are  we  worried  about?

v IV catheter placed in right cephalic

v PCV 27% TS 49 g/L
v Blood glucose 15 mmol/L

Traumatic  Brain  Injury Secondary  Brain  Injury

v Main consequences of brain injury v Consequences of brain injury

Ø Primary insult Ø Altered blood delivery and oxygenation
Ø  Direct result of accident Ø Progressive oedema, ischaemia and rises in ICP
Ø  Haemorrhage and neuronal injury Ø Neuronal injury
Ø Secondary insult
Ø  Result of primary insult
Ø  Continued haemorrhage, cerebral oedema, and
increased intracranial pressure (ICP)

Why  is  ICP  important? Definition

v Intracranial pressure (ICP)

v Impacts blood flow to the brain
Ø  pressure exerted by the intracranial contents
Ø  Brain tissue
v Major determinant of outcome
Ø  Blood
v Target of therapeutic interventions Ø  CSF
Ø  contained within non-compliant skull
v Limitations:
Ø No practical way to measure

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Cerebral  Blood  Flow Cerebral  Blood  Flow  and  MAP

v Driven by Cerebral Perfusion Pressure

CPP = MAP – ICP
v CPP must remain constant:
CPP = cerebral perfusion pressure
MAP = mean arterial blood pressure
Ø Overperfusion Cerebral oedema
ICP = intracranial pressure
Ø Underperfusion Cerebral ischemia

By maintaining MAP > 70 mmHg, can tolerate ICP of 20 mmHg

temporarily…. (normal ICP < 10 mmHg)

Primary  Brain  Injury Secondary  Brain  Injury

v Skull fracture fragments v Cerebral ischemia

v Subdural haemorrhage v Contributing factors:

Ø Hypotension
Ø Hypoxia
v Intracerebral haemorrhage
Ø Increased ICP – haemorrhage, oedema
Ø Increased cerebral metabolic rate
v Diffuse axonal injury

What  do  we  do? Traumatic  Brain  Injury

v Give fluids? v What things can we do?

v Measure blood pressure?
v Management
v Do more diagnostics? Ø Maintain adequate blood flow
Ø Minimise ICP
Ø Preventing further injury
v What do you make of the heart Ø Avoid iatrogenic damage
rate and pulse quality?

HR 110 bpm
Pulses tall and narrow

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Blood  Pressure Pressure  Autoregulation

v By supporting blood pressure – hope to maintain

cerebral perfusion
Ø Although remember that blood pressure does not
necessarily translate into perfusion
Ø Goal is to maintain Mean arterial pressure > 70 mmHg

v With brain injury there is zero tolerance for

hypotension

v Intravenous fluids
v Vasopressor therapy?

Fluid  Therapy
Fluid  Therapy

v Aims: v Choices:
Ø Isotonic crystalloid (eg. Hartmann’s, Lactated Ringer’s
Ø Maintain cerebral perfusion Solution, 0.9% Saline)
Ø Colloids (eg. Hetastarch, gelatins, whole blood, plasma)
Ø Hypertonic saline (3.2%, 7.5% saline)
Ø Avoid cerebral oedema
Ø Hypertonic colloids (RescueFlow®)

Ø Type of fluid?
Ø Rate of administration?

Fluid  Therapy Fluid  Therapy

v Almost all types of fluids adequate for resuscitation v Almost all types of fluids adequate for resuscitation
v Under certain circumstances, there may be a role of v Under certain circumstances, there may be a role of
hypertonic fluids hypertonic fluids

v Hypotonic fluids (eg 4% dextrose, 0.18% saline, 5%

dextrose)
Ø ABSOLUTELY CONTRAINDICATED

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Fluid  Therapy   Any  concerns  with  giving  this  dog  fluids?

v Isotonic crystalloid 20 ml/kg

v Isotonic colloid 5-10 ml/kg
v Hypertonic crystalloid 4-7 ml/kg
v Hypertonic colloid 4 ml/kg

Any  concerns  with  giving  this  dog  fluids?

v RR 38 bpm
v Very harsh lung sounds
v History of trauma

Fluid  Therapy  and  Pulmonary  Pathology When  do  you  worry  about  ICP?

v When should suspect elevation of ICP?

v Injured lungs do not tolerate fluid overload well
v May compromise oxygenation further
v Concerns with colloids as well as crystalloids
Ø Colloids with very large molecules - prolonged duration
v Should only administer as much fluids as necessary to
correct hypovolaemia

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When  should  you  suspect  elevation  in  ICP? Cushing  Reflex

v Increase in ICP – decreases CPP

v Body will attempt to restore CPP by increasing MAP
v Dull mentation, obtunded, coma v Systemic hypertension – causes increase cardiac output
v Cranial nerve abnormalities (progressive) – reflex bradycardia
v Presence of significant injuries
v Impending herniation
v Bradycardia
v Systemic hypertension
v Hypoventilation
v Irregular respiration

IC  Hypertension  Treatment IC  Hypertension  Treatment

v Brain v Brain
v Blood vessels v Blood vessels
v CSF v CSF

v Get rid of brain oedema!

IC  Hypertension  Therapy
IC  Hypertension  Treatment

v Mannitol
v Osmotic diuretics
Ø Also free-radical scavenger
Ø Mannitol: 0.25 g – 1 g/kg IV over 20 min
Ø Improves blood viscosity – improves perfusion
Ø Hypertonic saline 7.5%: 4 ml/kg over 20 min
Ø Hypertonic colloid: 4 ml/kg over 20 min v Hypertonic saline
Ø Down-regulates inflammation
v Will draw fluid from interstitium (brain) into intravascular Ø Less PMN adhesion
space

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Hyperglycaemia  and  Head  Injury

What  do  we  do  next?

v “Dexter’s” blood glucose 15 mmol/L

v Fluids administered
v Degree of hyperglycaemia parallels severity of neuronal
injury
v Steroids?
v Associated with worse outcome in people

v Pathological vs Indicator of severity?

Steroids  and  Brain  Injury

What  do  we  do  next?

v Considered contraindicated in brain injury

v Analgesia?
v No real benefits
Ø No stabilisation of membranes
Ø Not anti-inflammatory if given after injury
v Deleterious effects
Ø Promotes hyperglycaemia
Ø Increase risk of infections
Ø Poor outcome

Adjunct  Therapies Adjunct  Therapies

v Pain = ↑ sympathetic response = ↑ ICP
Ø Use analgesics – but must titrate to effect
Ø Just because animal not “acting” painful does not mean
significant injuries not painful
v If possible, keep head elevated 30 degrees
Ø Favours venous drainage, avoids increasing ICP
v Avoid making animal cough/sneeze
Ø Intubation
Ø Nasal oxygen catheters/canulas

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Adjunct  Therapy
What  about  hyperventilation?
v If an anaesthetic is required, i.e. other injuries
need attention:
v Smooth intubation: v Elevated PCO2 causes cerebral vasodilation
Ø Pre-medicate Ø ↑ ICP
Ø Use lidocaine gel/spray v Old recommendation was to hyperventilate patients
Ø Neuromuscular blocking agents to cause vasoconstriction
Ø Actually decreases cerebral perfusion
v Only should be used when suspicious of impending
herniation !

What  about  that  PCV? What  about  that  PCV?

v PCV 27% TS 49 g/L v PCV 27% TS 49 g/L

v Is this dog haemorrhaging?

What  about  that  PCV? What  do  you  do  now?

v PCV 27% TS 49 g/L v Give transfusion?

v Is this dog haemorrhaging? v Where is the bleeding?

v Repeat PCV 17% TS 40 g/L v Abdominal ultrasound?

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Haemorrhaging? Did  we  do  anything  that  could  have  

led  to  this?
v Ultrasound?
v One concern with hypertonic saline therapy is very rapid
v Abdominocentesis? expansion of intravascular volume
Ø Haemorrhagic
Ø PCV 15% v May precipitate on-going bleeding

What  do  you  do  now? What  do  you  do  now?

What  next? Concerns  with  belly  wraps

v Belly pressure wrap?? v Although may be appropriate for uncomplicated

traumatic haemoperitoneum …
v Surgery??
… May dramatically increase ICP!
… May also compromise respiratory system

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Summary

v Patients with trauma often suffer from multi-systemic

injuries
v Treatment strategies often conflict
v Must constantly re-assess patient
v Should focus on Major Body Systems
v Brain injury - perfusion is paramount, no steroids

Questions

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