Northeast Regional Trauma Council General Membership Meeting
St. Francis Hospital Meeting Room 1-2nd Floor
Topeka 1:00pm to 4:00pm
April 26, 2010
Minutes Cal to order and Welcome Dr. James Longabaugh called the meeting to order at 1:05pm. He “thanked” St. Francis Health Center for hosting the meeting. He asked all members to introduce themselves and the organization that they represent. Dr. Longabaugh reminded the members to complete their evaluations throughout the day, sign the sign-in roster, and complete their certificate of attendance. Legislative Advocacy & Session Update Due to other scheduling conflicts, Senator Schmidt was unable to present. Midwest Transplant Network Chad Bittle provided an overview of the Midwest Transplant Network and information on the number of people in our region awaiting transplants. Click here to view his presentation. Update on Public Health In Kansas Dr. Jason Eberhart—Phillips provided the presentation. His presentation provided information on HINI, Clean Indoor Act, and other KDHE legislative activities. Click here to view his presentation. Trauma System Development Rosanne Rutkowski provided the presentation. Her presentation provided information on the program’s achievements, current projects, and future goals. Click here to view her presentation. Interpreting Trauma Registry Data Dee Vernberg provided trauma registry data for the NE region and included information on trauma registry inclusion criteria, over and under triage, and data on the receipt of EMS patient care reports. Resuscitation of the Trauma Patient In the absence of Dr. Charlie Richart, Dr. Michael Moncure provided the presentation. Click here to view his presentation.
Subcommittee Updates
Education-Injury Prevention Darlene Whitlock and Liz Carlton provided the education and injury prevention update.
Injury Prevention Report NERTC hosted a Fall Prevention Workshop in December 2009. After the workshop was conducted, mini fall prevention grants were made available. Recipients of the grants were Health Innovations Network
of Kansas (HINK), Inc., Coffey County Hospital, University of Kansas Hospital, Lawrence Memorial Hospital, F.W. Huston Medical Center, Shawnee Mission Medical Center, and Pottawatomie County EMS. The regional trauma council provided funding to support the implementation of KDOT’s SAFE Teen Driving program in the region. The program allows high schools to compete against each other to increase seatbelt usage.
Education Report Classes supported in 2009-2010
o PHTLS Overland Park Regional Medical Center
Held June 2009
American Medical Response-Wabaunsee County Held October 2009
o TNCC
HINK-Coffey County Hospital Held August 2009
Ransom Memorial Hospital
Held March 2010
Mercy Hospital-Manhattan Held January 2010
o RTTDC
Lawrence Memorial Hospital Held September 2009
St. John’s Hospital-Leavenworth
Held December 2010
Upcoming: ATLS class, Stormont Vail on July 23rd & 24th.
The Trauma Program, the FLEX program and KFMC collaborated to conduct a trauma education needs assessment survey. A survey was sent to hospital administrators and ED managers and a survey was sent to EMS directors. The results of the survey were included in the meeting packet. The RTC would like to take the information gained from the survey and develop a plan/strategy to meet the needs identified in the survey. Click here to view trauma education needs assessment results.
Trauma Program Website: Organizations, as they schedule trauma education classes, were encouraged to send their course information to Jeanette to post on the trauma education calendar on the website.
Overview NERTC Strategic Plan
Liz Carlton provided the update on the NERTC’s strategic planning session that was conducted during the last two executive committee meetings utilizing a SWOT analysis. The SWOT analysis identifies strengths, weaknesses, opportunities, and threats. The committee identified three top priorities and developed action plans for each priority. The priorities identified are as follows: 1. Increase participation and active involvement with the RTC and NE region Action plan:
o ITV meetings/panel discussion in conjunction with the executive committee face-to-face meetings
o Referral question for the month o host bi-monthly referral questions with an expert panel (i.e.
physicians, nurses, EMS)—suggested topics can include fluid resuscitation, CT scanning, TBI, air transport vs. ground transport
o regional discussion beneficial to providers and patients o Archive and pod cast on trauma website o Letter of invitation-we need to get people involved, peer pressure-
physician to physician 2. Performance Improvement Action plan:
o Formalize the PI structure to be used for RTTDC PI component o Review regional PI aggregate data (standing agenda item) & look at
things we can target to improve patient outcomes o Suggested indicators for review
# of times a patient is transported prior to arrival at definitive care
over and under triage mortality via ISS transport times scene times
o Monthly-bimonthly ITV PI meetings-question of the month idea o PI workshop
o Dedicated folks o Invitation to participate with key leadership individuals (i.e.
administrators, risk managers, PI managers) o Highlight model level III programs
o Needs as much energy and action as system development and patient management, these components are critical and work hand in hand
Comments made: we are rich in data, data is absolutely useless if nothing is done with it. 3. Education
o Continue TNCC, RTTDC, PHTLS o Include prehospital in PI workshop & physician panel o Hold ATLS course on bi-annual basis
o include midlevel providers o alternate locations
o PI education
EMS Medical Director’s Association Dr. James Longabaugh provided information on the newly formed Kansas EMS Medical Director’s Association, which will be directed under the Kansas Medical Society. The development of the Association was in response to the NHTSA assessment that was conducted a couple a years ago, which indicated that the State of Kansas needs more involvement from the EMS Medical Directors across the state. In addition, an EMS Medical Director Workshop was conducted last fall and is scheduled to be held on an annual basis. The KBEMS asked the association to develop a medical advisory committee that would advise them on topics as needed. To formalize the committee, language was introduced under SB262, which has passed. Eight members from the Association make up the advisory committee. The members of the Association have met several times by phone and the first face-to-face meeting is scheduled in Wichita next month. The committee has tentatively scheduled this year’s annual EMS Medical Director Workshop to be held in October. The goal of the association is to help advance EMS in the state, ensure that everyone is on the same page, help with protocol development of guidelines/standards, and in areas of the state where there is no medical direction, provide medical direction by reviewing and signing protocols. The NERTC scheduled an EMS Medical Director Workshop for the region this past fall. The executive committee viewed the regional workshop as an opportunity to provide information that was relevant to the NE region. Due to the minimal response, the workshop was cancelled. Bylaws Revision (Action) The proposed bylaw revisions included changing the way the officers of the executive committee are elected. The bylaw language suggested changes allowing the executive committee to vote on officers as opposed to the general membership electing the officers. Elaine Swisher, Lawrence Memorial Hospital, made the motion to approve the bylaws with the change. Dr. Deborah Smith, Jackson County EMS, seconded the motion. The motion passed. In closing The University of Kansas donated a registration to the Midwest Trauma Society meeting scheduled in May in Kansas City. A raffle was held. The winner of the registration raffle was Thomas Weidmaier, Providence Medical Center. Dr. Longabaugh reminded participants to sign the registration roster, complete the certificate of attendance and the meeting evaluation form. Dr. Longabaugh “thanked” St. Francis again for hosting the meeting and “thanked” everyone for attending. Adjournment The meeting adjourned at 4:10pm.
The EDand the
Management of Potential Organ
Donors
The EDand the
Management of Potential Organ
DonorsSt. FrancisApril 2010St. FrancisApril 2010
WHY IS DONATION IMPORTANT?
WHY IS DONATION IMPORTANT?
Joint Commission Initiativesto Increase Organ Donation
Every 12 minutes another name is added to the national waiting list
19 people will die waiting for an organ transplant every day
+1,000,000 people benefit from a tissue transplant each year
Every 12 minutes another name is added to the national waiting list
19 people will die waiting for an organ transplant every day
+1,000,000 people benefit from a tissue transplant each year
Who Is Midwest Transplant Network?
Who Is Midwest Transplant Network?
Midwest Transplant Network ServicesMidwest Transplant Network Services
• Incorporated in 1972 as the federally designated procurement agency for Kansas and the Western 2/3 of Missouri. > 300 Hospitals and Facilities
• Satellite OfficesColumbia, MissouriWichita, KansasJoplin, Missouri
• Incorporated in 1972 as the federally designated procurement agency for Kansas and the Western 2/3 of Missouri. > 300 Hospitals and Facilities
• Satellite OfficesColumbia, MissouriWichita, KansasJoplin, Missouri
HeadquartersHeadquarters
SatelliteSatellite OfficesOffices
Transplant Centers MTN Service Area
Transplant Centers MTN Service Area
Children’s Mercy Hospital (Liver, Kidneys, Heart Valves)KU Medical Center (Liver, Kidneys, Pancreas)Research Medical Center (Kidneys, Pancreas)St. Francis Hospital, WI (Liver, Kidneys, Pancreas)St. Luke’s Hospital (Heart, Kidneys)Univ. of MO Hospitals, Columbia (Kidneys)
Children’s Mercy Hospital (Liver, Kidneys, Heart Valves)KU Medical Center (Liver, Kidneys, Pancreas)Research Medical Center (Kidneys, Pancreas)St. Francis Hospital, WI (Liver, Kidneys, Pancreas)St. Luke’s Hospital (Heart, Kidneys)Univ. of MO Hospitals, Columbia (Kidneys)
Functions and ServicesMidwest Transplant Network
Functions and ServicesMidwest Transplant Network
Coordination of organ,tissue, and eye donation including evaluation, procurement and allocation of organs and tissueProfessional education/consultation Donor family support services
Coordination of organ,tissue, and eye donation including evaluation, procurement and allocation of organs and tissueProfessional education/consultation Donor family support services
Functions and ServicesMidwest Transplant Network
Functions and ServicesMidwest Transplant Network
• Community education• Clinical laboratory, expert in
histocompatibility, molecular technology
• 24 hr. communication center to answer referral calls from our service area
• Community education• Clinical laboratory, expert in
histocompatibility, molecular technology
• 24 hr. communication center to answer referral calls from our service area
MTN ResponsibilitiesMTN Responsibilities
MTN’s Clinical Coordinators are Critical Care RNs and RTs with specialized training/certification in donor management they stay with the patient throughout entire caseMedical Director off site who assumes responsibility for the donor
MTN’s Clinical Coordinators are Critical Care RNs and RTs with specialized training/certification in donor management they stay with the patient throughout entire caseMedical Director off site who assumes responsibility for the donor
Referral: A Nursing InterventionReferral: A Nursing InterventionReferral of a potential donor is the single most important factor in increasing the supply of organs and tissue for transplantationMade within one hour after meeting clinical triggers1-800-DONOR 91
Referral of a potential donor is the single most important factor in increasing the supply of organs and tissue for transplantationMade within one hour after meeting clinical triggers1-800-DONOR 91
Success in the ER does matter!!Success in the ER does matter!!Pt: J.R. 30y/o M AA GSW to head and right armGCS: 14 in the field Deteriorated quickly in route to hospital.Pt arrived unresponsive in ERIntubated and placed on vent. CT for scan of head and spine. Stabilized by ER staff and imminent death referral made to MTN
Pt: J.R. 30y/o M AA GSW to head and right armGCS: 14 in the field Deteriorated quickly in route to hospital.Pt arrived unresponsive in ERIntubated and placed on vent. CT for scan of head and spine. Stabilized by ER staff and imminent death referral made to MTN
CT Head and NeckCT Head and Neck
Two gunshot wounds with bullet fragments, right subdural hematomas and intraparenchymal hemorrhages, pneumocephalus, right-to-left midline shift with cerebral edemaRadiopaque foreign body at the level of C6-7, no acute fractures or dislocations
Two gunshot wounds with bullet fragments, right subdural hematomas and intraparenchymal hemorrhages, pneumocephalus, right-to-left midline shift with cerebral edemaRadiopaque foreign body at the level of C6-7, no acute fractures or dislocations
Approximately 24 hours later pronounced Brain Dead, family
chose organ and tissue donation
Approximately 24 hours later pronounced Brain Dead, family
chose organ and tissue donation
Average BP in ER 122/59 (84), low 84/54Received 2000ml CrystalloidsStarted on Levophed to maintain BPK 3.2, glucose 240 (otherwise normal)ABG 7.19/36/397/13/-13Pt transferred to NSICU after 45 minutes
Average BP in ER 122/59 (84), low 84/54Received 2000ml CrystalloidsStarted on Levophed to maintain BPK 3.2, glucose 240 (otherwise normal)ABG 7.19/36/397/13/-13Pt transferred to NSICU after 45 minutes
Catastrophic Brain Injury GuidelinesCatastrophic Brain Injury GuidelinesCatastrophic Brain Injury Guidelines
Consider obtaining a critical care consult if not already involved in patient care Maintain SBP > 100 (MAP > 60)
1. Consider invasive hemodynamic monitoring 2. Adequate hydration: Ensure adequate hydration to maintain euvolemia 3. Vasopressor support: If hypotensive post adequate rehydration, utilize Neosynephrine as the first pressor of choice up to 2mcg/kg/min followed by Dopamine if needed
Maintain Urine Output > 0.5ml/kg/hr < 400ml/hr (consider DI if > 400ml/hr x2 hours) 1. Treat Diabetes Insipidus with Vasopressin drip 1-2.5u/hr, if UO still > 400ml/hr,
give DDAVP 0.5 mcg IVP every 2-3 hours 2. If UO falls below 0.5ml/kg/hr, assess fluid status-may need rehydration or BP
support Maintain PO2 > 100 & pH 7.35-7.45
1. Adequate ventilation: 5.0-8.0 PEEP aggressive respiratory hygiene if not contraindicated by patient’s condition (suction and turn every 2 hours) respiratory treatments to prevent bronchospasm Other orders to consider:
1. Monitor and treat electrolytes maintaining the following: Sodium: 134 – 145 mmol/L Potassium: 3.5 – 5.0 mmol/L Magnesium: 1.8 – 2.4 meq/L Phosphorus: 2.0 – 4.5 mg/dL Ionized Calcium: 1.12 – 1.3 mmol/L
2. Monitor glucose and treat with insulin drip if needed (keep 80-200) rather than
SQ 3. Monitor and treat Hgb/Hct/coagulation factors (especially if GSW or other
penetrating head injury) Maintain Hgb > 8.0 g/dL and Hct > 24% If PT > 18.0 give 2u FFP If Fibrinogen 70-100 give 2u FFP, if < 70 give cryoprecipitate If platelets < 50 give 6pk of platelets *remember to recheck labs after treatment
4. Maintain temp 36-37.5 Celsius with bair hugger/warming-cooling blanket
Catastrophic Brain Injury Guidelines Consider obtaining a critical care consult if not already involved in patient care Maintain SBP > 100 (MAP > 60)
1. Consider invasive hemodynamic monitoring 2. Adequate hydration: Ensure adequate hydration to maintain euvolemia 3. Vasopressor support: If hypotensive post adequate rehydration, utilize Neosynephrine as the first pressor of choice up to 2mcg/kg/min followed by Dopamine if needed
Maintain Urine Output > 0.5ml/kg/hr < 400ml/hr (consider DI if > 400ml/hr x2 hours) 1. Treat Diabetes Insipidus with Vasopressin drip 1-2.5u/hr, if UO still > 400ml/hr,
give DDAVP 0.5 mcg IVP every 2-3 hours 2. If UO falls below 0.5ml/kg/hr, assess fluid status-may need rehydration or BP
support Maintain PO2 > 100 & pH 7.35-7.45
1. Adequate ventilation: 5.0-8.0 PEEP aggressive respiratory hygiene if not contraindicated by patient’s condition (suction and turn every 2 hours) respiratory treatments to prevent bronchospasm Other orders to consider:
1. Monitor and treat electrolytes maintaining the following: Sodium: 134 – 145 mmol/L Potassium: 3.5 – 5.0 mmol/L Magnesium: 1.8 – 2.4 meq/L Phosphorus: 2.0 – 4.5 mg/dL Ionized Calcium: 1.12 – 1.3 mmol/L
2. Monitor glucose and treat with insulin drip if needed (keep 80-200) rather than
SQ 3. Monitor and treat Hgb/Hct/coagulation factors (especially if GSW or other
penetrating head injury) Maintain Hgb > 8.0 g/dL and Hct > 24% If PT > 18.0 give 2u FFP If Fibrinogen 70-100 give 2u FFP, if < 70 give cryoprecipitate If platelets < 50 give 6pk of platelets *remember to recheck labs after treatment
4. Maintain temp 36-37.5 Celsius with bair hugger/warming-cooling blanket
Catastrophic Brain Injury GuidelinesBuilding the FoundationCatastrophic Brain Injury GuidelinesBuilding the Foundation
Catastrophic Brain Injury GuidelinesBuilding the Foundation
Catastrophic Brain Injury GuidelinesBuilding the Foundation
Maintain Systolic BP > 100 MAP > 60
Consider invasive hemodynamic monitoringAdequate hydrationVasopressor support
Maintain Systolic BP > 100 MAP > 60
Consider invasive hemodynamic monitoringAdequate hydrationVasopressor support
Catastrophic Brain Injury GuidelinesBuilding the Foundation
Catastrophic Brain Injury GuidelinesBuilding the Foundation
Catastrophic Brain Injury GuidelinesBuilding the Foundation
Catastrophic Brain Injury GuidelinesBuilding the Foundation
Maintain Urine Output Between 0.5 ml/kg/hr - 3 ml/kg/hr
Consider DI if > 400 ml/hr for two hoursTreat DI with Vasopressin drip 1 – 2.5 u/hr
If UO continues to be > 400 ml/hr, give DDAVP 0.5 mcg IVP every 2-3 hours
If UO falls below 0.5 ml/kg/hour, assess fluid status
May need Hydration or BP support
Maintain Urine Output Between 0.5 ml/kg/hr - 3 ml/kg/hr
Consider DI if > 400 ml/hr for two hoursTreat DI with Vasopressin drip 1 – 2.5 u/hr
If UO continues to be > 400 ml/hr, give DDAVP 0.5 mcg IVP every 2-3 hours
If UO falls below 0.5 ml/kg/hour, assess fluid status
May need Hydration or BP support
Catastrophic Brain Injury GuidelinesBuilding the Foundation
Catastrophic Brain Injury GuidelinesBuilding the Foundation
Catastrophic Brain Injury Guidelines Building the FoundationCatastrophic Brain Injury Guidelines Building the Foundation
Maintain PO2 > 100Maintain pH 7.35-7.45Maintain adequate Ventilation
Peep 5-8Aggressive respiratory hygiene is not contraindicated by patient’s condition
Suction every two hoursRespiratory tx to prevent bronchospasms
Maintain PO2 > 100Maintain pH 7.35-7.45Maintain adequate Ventilation
Peep 5-8Aggressive respiratory hygiene is not contraindicated by patient’s condition
Suction every two hoursRespiratory tx to prevent bronchospasms
Catastrophic Brain Injury Guidelines Building the FoundationCatastrophic Brain Injury Guidelines Building the Foundation
Catastrophic Brain Injury Guidelines Building the FoundationCatastrophic Brain Injury Guidelines Building the Foundation
Monitor and treat electrolytesSodium 134-145Potassium 3.5-5.0Magnesium 1.8-2.4 Phosphorus 2.0-4.5Ionized Calcium 1.12-1.3
Monitor and treat electrolytesSodium 134-145Potassium 3.5-5.0Magnesium 1.8-2.4 Phosphorus 2.0-4.5Ionized Calcium 1.12-1.3
Catastrophic Brain Injury Guidelines Building the FoundationCatastrophic Brain Injury Guidelines Building the Foundation
Catastrophic Brain Injury Guidelines Building the FoundationCatastrophic Brain Injury Guidelines Building the Foundation
Monitor glucose and treat with insulin drip if needed rather than SQ
Keep between 80-200Monitor and Treat Hgb/HCT/Coags
HGB > 8.0 g/dLHCT > 24%PT < 18.0Fibrinogen > 100Platelets > 50
Maintain Normal Temperature36-37.5 CCan use bair hugger or cooling blanket
Monitor glucose and treat with insulin drip if needed rather than SQ
Keep between 80-200Monitor and Treat Hgb/HCT/Coags
HGB > 8.0 g/dLHCT > 24%PT < 18.0Fibrinogen > 100Platelets > 50
Maintain Normal Temperature36-37.5 CCan use bair hugger or cooling blanket
Reviewing J.R.’s stability at the beginning of organ donor management
Reviewing J.R.’s stability at the beginning of organ donor management
MAP 78UOP 700ml in last hourpH 7.43pO2 on 100% 467Levophed 8mcg/minNa 161, glucose 143
MAP 78UOP 700ml in last hourpH 7.43pO2 on 100% 467Levophed 8mcg/minNa 161, glucose 143
Success is measured with the recipientsSuccess is measured with the recipientsHeart: Ischemic Cardiomyopathy, 61 y/o MLungs: Cystic Fibrosis, 32 y/o FLeft segment of Liver:
Acute Failure, 1 month old MLiver: Chronic Failure, 41 y/o MRight Kidney: Lupus, 25 y/o MLeft Kidney/Pancreas: DM Type I, 37 y/o M
Heart: Ischemic Cardiomyopathy, 61 y/o MLungs: Cystic Fibrosis, 32 y/o FLeft segment of Liver:
Acute Failure, 1 month old MLiver: Chronic Failure, 41 y/o MRight Kidney: Lupus, 25 y/o MLeft Kidney/Pancreas: DM Type I, 37 y/o M
1
Slide 1KDHE Vision: Healthy Kansans living in safe and sustainable environments
Public Health Update
Northeast Kansas Trauma Region Annual Meeting
Jason Eberhart-Phillips, MD, MPHState Health Officer and Director
of Health, KDHE
A Whole New Kind of Flu• Global emergence of an
entirely new flu virus • By sheer luck this virus is
not usually a killer– 100 times less lethal
than the 1918 flu virus• Still, by mid-March 2010
– 60 million cases in US– Approximately 270,000
hospitalizations– > 12,000 deaths
The “Third Wave” Never Came Herd Immunity In Action
Vaccine: A Huge Success• In just over three
months >889,000 vaccine doses were distributed in KS!– An unprecedented
statewide mobilization– Every local health
department in the lead– >1000 private providers– Thousands of volunteers
staffing public clinics
Kansas Vaccine Uptake
2
Slide 7KDHE Vision: Healthy Kansans living in safe and sustainable environments
Luck Has Been on Our Side…• Disease virulence is low• Virus is genetically stable• Transmissibility is high, but
could’ve been higher• Vaccine induces a strong,
fast, immune response• Most people require only a
single dose of vaccine• It is as safe as expected
Slide 8KDHE Vision: Healthy Kansans living in safe and sustainable environments
…Most of the Time!• Predictions of ample
vaccine supplies were overly optimistic– Up to 160 million doses
expected by October 31– Received less than 30
million– One of the poorest
producing vaccine virus strains ever seen
– Just 0.2 - 0.6 doses/egg
Slide 9KDHE Vision: Healthy Kansans living in safe and sustainable environments
Statewide Clean Indoor Act• Kansas is now the
40th state to assure protection from second hand smoke in public places– Implementation now
underway– Educating businesses– KsSmokeFree.Org
Slide 10KDHE Vision: Healthy Kansans living in safe and sustainable environments
Primary Seat Belt Law• Carry over bill (HB
2130) passed by the Senate
• May yet be approved by the House
• Over $10 million in one-time federal funds incentive for the state
Slide 11KDHE Vision: Healthy Kansans living in safe and sustainable environments
KDHE Bills• SB 62 passed and signed –
implements new standard TB screening process for all Kansas post secondary educational institutions
• SB 62 includes SB 147 which implements an “opt out” process for universal screening of pregnant women for HIV infection
Slide 12KDHE Vision: Healthy Kansans living in safe and sustainable environments
More KDHE Bills• SB 488 authorizes criminal background
checks for KDHE employees with access to sensitive birth and death data
• Bill includes SB 448 – recommended by the Blue Ribbon Panel on Infant Mortality – which authorizes research related to causes of infant mortality based on birth certificate information
• Hung up currently in conference
3
Slide 13KDHE Vision: Healthy Kansans living in safe and sustainable environments
More KDHE Bills• SB 531 establishes a certification
program for contractors who perform testing and remediation for radon in residential settings: PASSED
• SB 499 would set standards for healthy foods in school vending machines– Was heard in Senate Education Committee,
but no action was taken
Slide 14KDHE Vision: Healthy Kansans living in safe and sustainable environments
More KDHE Bills• SB 505 Menu labeling
for chain restaurants• Had informational
hearing in Senate Public Health and Welfare Committee
• Similar requirements were included in the national health care reform legislation, so no action is needed in KS
Slide 15KDHE Vision: Healthy Kansans living in safe and sustainable environments
Other Bills of Interest• HB 2356 now includes
content from SB 447 • Sets new supervision
standards for day care • Requires inspection of
registered day care homes• And development of a risk-
based system to determine frequency of inspections for child care facilities
Slide 16KDHE Vision: Healthy Kansans living in safe and sustainable environments
Other Bills of Interest• HB 2596 would have
limited KDHE regulations for lead based paint contractors who repair or renovate houses built before 1978
• Compromise was achieved, making changes in the regulations for the program so that the bill did not go forward
Slide 17KDHE Vision: Healthy Kansans living in safe and sustainable environments
www.kdheks.gov
To Protect the Health and Environment of all Kansans To Protect the Health and Environment of all Kansans by Promoting Responsible Choicesby Promoting Responsible Choices
1
Our Vision - Healthy Kansans living in safe and sustainable environments
NE Regional Trauma Council General Membership Meeting
Our Vision - Healthy Kansans living in safe and sustainable environments
2010 Trauma System Update
Rosanne Rutkowski, RN, MPHKansas Trauma Program [email protected]
Our Vision - Healthy Kansans living in safe and sustainable environments
Welcome & Thank You!
Update on State Priority projects Level IV
Federal Trauma Care & Health Care Reform
Regional Education Regional Trauma Plan
Our Vision - Healthy Kansans living in safe and sustainable environments
Goals of the Kansas Trauma System
Reduce the number of preventable deaths Improve outcomes for traumatic injuries Encourage provider preparation and response to
trauma Reduce medical costs through appropriate use of
resources Increase public awareness & prevention Design an inclusive and comprehensive system Develop trauma education resources
Kansas Trauma Plan 2001
Our Vision - Healthy Kansans living in safe and sustainable environments
State Trauma Program: Infrastructure
KDHE: Lead Agency Regional Trauma Councils Advisory Committee on Trauma Trauma Registry Trauma Center designation
Advisory Committee on Trauma Appointed by the Governor's office
Regional Trauma Councils Hospitals- administrators, physicians, nurses EMS Public Health Departments
Our Vision - Healthy Kansans living in safe and sustainable environments
Projects: 2009
Level III trauma center grants Developed Level IV criteria Updated Regional Trauma Plans Updated Data Benchmark Report 2009 Annual Report & newsletter 1st State EMS Medical Director’s Conf. Listserv and Report Writer Training
2
Our Vision - Healthy Kansans living in safe and sustainable environments Our Vision - Healthy Kansans living in safe and sustainable environments
Our Vision - Healthy Kansans living in safe and sustainable environments
State Designated Trauma Centers:
Level I Trauma Centers University of Kansas Hospital Via Christi- St. Francis Wesley Medical Center
Level II Trauma Centers Overland Park Regional Medical Center Stormont Vail Regional Health Center
Level III Trauma Centers Labette Health Via Christi- Pittsburg
Our Vision - Healthy Kansans living in safe and sustainable environments
Our Vision - Healthy Kansans living in safe and sustainable environments
Projects 2010
Priority Assessment- 5/2010 Update regulations to include Level IV
trauma center Cont. Level III trauma center grants Update state trauma registry system On-line training
Develop interface EMS/trauma Data Awarded CDC Funding for field triage
Our Vision - Healthy Kansans living in safe and sustainable environments
Proposed Level IV criteria:
Trauma Team Education requirements Physician- ATLS ER Nurse- TNCC
Trauma Team Activation Plan On call schedule Equipment for resuscitation Quality improvement program Transfer protocol
3
Our Vision - Healthy Kansans living in safe and sustainable environments
Trauma/EMS Interface
Board of EMS & KTP awarded a grant from KDOT to support interface
6-8 months completion EMS Data will be downloaded into the
trauma registry 2 data elements will be provided back
to EMS
Our Vision - Healthy Kansans living in safe and sustainable environments
Trauma/EMS Data Interface
Our Vision - Healthy Kansans living in safe and sustainable environments
Training & Education:
Establish min. standards for trauma care Prehospital PHTLS
Nurses TNCC
Physicians ATLS
Hospitals Rural Trauma Team Development (RTTDC)
Our Vision - Healthy Kansans living in safe and sustainable environments
Trauma Education Needs Survey
Trauma Education Funding Sources: Kansas Rural Health Options Project (KRHOP) Regional Trauma Councils Christopher & Dana Reeves Foundation Grant-
applied for
KRHOP Funds: RTTDC, ATLS, PHTLS, TNCC $1,500 RTTDC $1,000 PHTLS $1,500 TNCC $1,000 ATLS scholarships ( 20)
Outcome?
Our Vision - Healthy Kansans living in safe and sustainable environments
100.0%95.8%160167Total
11.9%95.0%1920SW
11.9%95.0%1920SE
30.0%98.0%4849SC
11.9%95.0%1920NW
23.8%92.7%3841NE
10.6%100.0%1717NC
Respond‐ingTotal
% of All Respond‐ing
Response Rate
# of EMS Services*
Region
Response Totals by Region
*Represents all Critical Access Hospitals, and acute care facilities providing trauma services.
100.0%100.0%127127Total
14.2%100.0%1818SW
11.0%100.0%1414SE
24.4%100.0%3131SC
14.2%100.0%1818NW
26.0%100.0%3333NE
10.2%100.0%1313NC
Respond‐ingTotal*
% of All Respond‐ing
Response Rate
# of Hospitals
Region
Response Totals by Region
EMS/Hospital Survey Response
Our Vision - Healthy Kansans living in safe and sustainable environments
# Needing ATLS Training
51
188
48 37 49
127
0
50
100
150
200
250
300
NC NE NW SC SE SW
% Needing ATLS Training
63.0%54.5%
63.2%
41.6%
60.5%50.2%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
NC NE NW SC SE SW
Need for ATLS
MD, PA, ARNP providing ED coverage as primary care provider: Total Number 345# w/ ATLS: 157, #needing ATLS: 188 ( 55% need ATLS)
4
Our Vision - Healthy Kansans living in safe and sustainable environments
# Needing TNCC Training
91 83
166136
65
297
0
50
100
150
200
250
300
NC NE NW SC SE SW
% Needing TNCC Training
32.3%48.7%
28.6%34.9%31.7%
45.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
NC NE NW SC SE SW
Need for TNCC
RN, LPN providing care in ED, Total 938# w/ TNCC: 641, # needing 297 (32% need TNCC)
Our Vision - Healthy Kansans living in safe and sustainable environments
# Needing PHTLS Training
1146
294192
784
308303
0
200400
600800
10001200
1400
NC NE NW SC SE SW
% Needing PHTLS Training
80.8% 77.4%
60.3% 61.5%51.8%70.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
NC NE NW SC SE SW
Need for PHTLS
Attendants( 1st responders, EMTs, Paramedics) providing care in your service Total: 1638# needing PHTLS: 1146, # w/ PHTLS; 492 ( 70% need PHTLS)
Our Vision - Healthy Kansans living in safe and sustainable environments
TNCC Requirement: NE33 Hospitals
No: 1236%Yes: 18
55%
Don't know 39%
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TNCC Requirement: Statewide 127 hospitals
No: 5342%Yes: 69
54%
Don't know: 54%
Our Vision - Healthy Kansans living in safe and sustainable environments
ATLS Requirement: NE 33 hospitals
No: 1855%
Don't Know 721%
Yes: 824%
Our Vision - Healthy Kansans living in safe and sustainable environments
ATLS Requirement: Statewide 127 Hospitals
Don't Know: 2016%
Yes: 3326%
No: 7458%
5
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1604518NW
12621425NC
16384332NE
3132539SW
2143620SE
5412235SC
ATLSRTTDCTNCCPHTLS
RTC- Trauma Education 2009
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CDC Field Triage Implementation Project
Awarded funding from CDC Kansas, Massachusetts, Michigan
Goal: Pilot Field Triage Guidelines in state/region
9-member leadership team SE Regional Trauma Region will serve
as pilot area
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Field Triage Decision
Scheme: The National
Trauma Triage Protocol
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Our Vision - Healthy Kansans living in safe and sustainable environments
Federal: Health Care Reform
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Health Care Reform
Emergency & Trauma Care Systems Support regionalized, coordinated and
accountable emergency care Funds appropriated FY11 for research in
emergency medicine & regionalized emergency care systems
Mandate & fund integrated trauma system development Establishes new trauma center program to
strengthen ED & trauma center capacity
6
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Regional Trauma Council Funding2009
54%
26%
1%15%
4%
0%
Education: Prevention: Meetings: PI: Administration EMD
Our Vision - Healthy Kansans living in safe and sustainable environments
NE Regional Trauma Council 2009 $23,472
Administration:$1,3586%
Meetings: $1,450 6%
Prevention: $3,000 13%
Education: $17,520 75%
Education: $17,520 Prevention: $3,000Meetings: $1,450 Administration:$1,358
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NE RTC Budget: 2010
Education: $8,900Admin. : $1,358Prevention: $6,000Meetings: $2,550PI: $1,300Other: $ 14
Total: $20,121
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Regional Trauma Plans
Regional Plans Reviewed & Updated:2005, 2007, 2009
2009 Recommendations Tailor & adopt CDC field triage guidelines Support trauma education assessment Injury prevention based on trauma data Identify a legislative liaison in ea. region Include executive summary in future
plans
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Regional Trauma Councils
Cornerstone of the state system An opportunity for input into the state system Opportunity to become involved at regional level Responsible for assessing regional resources Responsible for identifying educational needs and
then providing education Responsible for community prevention efforts
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Kansas Trauma Program
Web site: www.kstrauma.org ACT Regional Trauma Council Education Regulations Publications Contact information Newsletter
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Kansas Trauma Program StaffRosanne Rutkowski, RN, MPHProgram Director
Dan Robinson, MBAAssistant Program Coordinator
Dee Vernberg, PhD, MPHTrauma Epidemiologist
Jeanette ShipleyRegional Trauma Coordinator
Dan RussellDatabase Administrator
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Thank you for your support
End Points of Resuscitation in the Trauma Patient
Charles Richart, MD, FACS,FCCM
SHOCK
• Shock is cardiovascular collapse– Systemic hypoperfusion owing to
reducation either in cardiac output or in effective circulating blood volume
– End results=hypotension followed by impaired tissue perfusion and cellular hypoxia
Physiology
• Systemic tissue perfusion– Determined by Cardiac Output (CO) and
systemic vascular resistance (SVR)
– CO= HR x SV• Stroke volume is related to preload, myocardial
contractility, and afterload
• SVR= vessel length, blood viscosity, inverse vessel diameter
Stages of Shock
• Nonprogressive phase / Preshock– Warm shock or Compensated shock
– Compensatory mechanisms are activated• Baroreceptor reflexes release catecholamines,
activate renin-angiotension axis, ADH
– Perfusion of organs is maintained
Stages of Shock
• Progressive Stage– Compensatory mechanisms are overwhelmed
– Tissue hypoperfusion and onset of worsening circulatory and metabolic imbalances
• Widespread tissue hypoxia
• Persistent Oxygen deficit, proceeded by anaerobic metabolism, which will cause lactic acidosis
• Microcirculation becomes stagnant at times, causing pooling, increasing hypoxic injury and risk of DIC
Stages of Shock
• Irreversible Shock / End-Organ dysfunction– Occurs after the body has sustained cellular
and tissue injury so severe hemodyanmic or organ recovery is impossible.
– Myocardial contractility worsens
– MODS
– Death
Hypovolemic Shock
• Loss of blood volume and oxygen carrying red blood cells resulting in inadequate oxygen delivery to tissues– Hemorrhage induced or fluid loss induced
• Estimate of patient’s circulating blood volume:– 7% of body weight=total blood volume (TBV)
• 70kg x .07= 4.9 L TBV
• During hemorrhage interstitial fluild shifts to intracellular and intravascular space– This will dilute RBC’s and decrease H/H
Causes Hypovolemic Shock
• Internal Bleeding• Pancreatitis• Trauma• Surgery• Fracture
– Estimated blood loss from fractures
• Rib=100mL• Humerous=250mL• Tib/Fib=250-500mL• Femur=1000mL• Pelvis=500-3000 mL
Assessment of Hypovolemic Shock
• Lab: decrease H/H, serum Na+ could increase with hypertonic solutions, decrease potassium and calcium, decrease Platelets
• Neuro: c/o thrist, lethargic, dilated but reactive pupils
• GI/GU: decrease UO due to aldosterone and ADH release, urine Na+ may decrease, can go into ARF/ATN
Assessment of Hypovolemic Shock
• Cardiac: decrease peripheral pulses• Lungs: tachypnea• Skin: decrease temperature, pale• Hemodynamics:
– Increase HR– Decrease PCWP (preload), decrease CVP– Decrease CO (pump function)– Increase SVR (afterload)– Decrease BP– Increase respiratory rate– Decrease UO
Treatment of Hypovolemic Shock
• Find and control bleeding or fluid loss• Need large bore IV’s to give fluid quickly• Replace lost fluid: LR 3:1 ratio
– 3mL of LR for every 1mL of EBL
• Give blood if severe/profound shock– Hct <28% (Hct <30% with elderly)
www.emsprime.com/images/Shock.png
Reliability of FAST
• Meta-analysis of 62 studies with over 18,000 total scans performed
• Pooled overall sensitivity 79% • Pooled overall specificity 99% • Overall bias-adjusted sensitivity is low in
FAST
Stengel, et al. Association between Compliance with Methodologic Standards of Diagnostic Research and Reported Test Accuracy: Meta-analysis of Focused Assessment of US for Trauma. Radiology, 2005; 236:102.
Reliability of FAST
• Penetrating anterior chest trauma • 32 patients, 65% stab wounds, 35% GSW • 100% sensitivity and specificity for pericardial effusion• 100% sensitivity and specificity for intraperitoneal fluid • FAST effective guide for surgical decision making in
anterior penetrating chest trauma
Tayal, et al. FAST (Focused Assessment With Sonography in Trauma) Accurate for Cardiac and Intraperitoneal Injury in Penetrating Anterior Chest Trauma. J Ultrasound Med 2004; 23:467-472.
Base Deficit
• 2069 trauma patients admitted to ICU• Worsening base deficit = mortality of 45% in patients
with BD > 6• Incr in BD directly assoc with decr SBP, incr PT, incr in
HR and lactate levels as well as mortality with p<0.0001• BD > 10 also was noted to be assoc with higher
transfusion requirements (14 units PRBCs) • BD may guide early and aggressive resuscitation
Rixen, D, et al. Base deficit development and its prognostic significance in posttrauma critical illness: An analysis by the trauma registry of the Deutsche Gesellschaft fur Unfallchirurgie. Shock 2001; 15 (2) : 83-89.
Base Deficit
• 3791 trauma patients admitted with ABG in first 24 hours
• Matched on mechanism, TRISS, age, etc.• Most (80%) had base deficit• Age < 55, no head injury and BD -15 assoc with 25%
mortality• Age 55 with no head injury OR Age <55 with head injury
25% mortality for BD -8
Rutherford, E, et al. Base Deficit Stratifies Mortality and Determines Therapy. J of Trauma 1992 Sept; 33(3) : 417-423.
Coagulopathy
• 40% of trauma fatalities are due to hemorrhagic shock, most are coagulopathic at death
• Hypothermia, Acidosis, Coagulopathy – “Lethal Triad”
• DIC “Death Is Coming”– In severe hemorrhage, elevated INR, PT, PTT with
thrombocytopenia and low fibrinogen
Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J of Trauma 1995; 38 : 185-193.
Coagulopathy
• Why? • We worsen coagulopathy by DILUTION
– Dilution of coagulation factors
– Calcium used in activation and not replaced
• We DILUTE with COLD fluids• Acidosis is present and worsening as long as tissue
hypoxia present, i.e. we don’t get CONTROL of bleeding
Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J of Trauma 1995; 38 : 185-193.
Coagulopathy
• How do we promote coagulation in massive hemorrhage/ massive transfusion?
• Novo 7 (recombinant VIIa)– Still controversial
• Thrombin, GelFoam, Surgicel and similar products• UT Houston study Trauma Mortality, the Lethal Triad and Massive
Transfusion– Fixed Acidosis and Hypothermia– Behind on blood products– Recommendation of EARLY FFP and FFP to PRBC ratio 1:1 in
massive transfusion
Gonzalez E, Moore FA, et al. Fresh frozen plasma should be given earlier to the patient requiring massive transfusion. J of Trauma 2007; 62 (1) : 112-119.
Recombinant VIIa
• Although controversial, recent data out of Iraq • Combat casualty patients, ISS >15 and required massive
transfusion (10 units/ 24 hrs) • 49 received VIIa
– 24 hr mortality 7 of 49 (14%)– 30 d mortality 15 of 49 (31%)
• 75 did not receive VIIa– 24 hr mortality 26 of 75 (35%)– 30 d mortality 38 of 75 (51%) p=0.03
Spinella P, Perkins, J, et al. The Effect of Recombinant Activated VII on Mortality in Combat-Related Casualities With Severe Trauma and Massive Transfusion. J of Trauma 2008 Feb ; 64 (2) : 286-294.
Fluid Resuscitation
• What type and when? Also controversial• Smaller volume resuscitations using hypertonic saline
– Patients requiring massive transfusion– Prevent complications like ARDs, studies are ongoing– Delayed vs Immediate Resuscitation
• Isotonic Warm Fluids are certainly the standard of care• Ratios of resuscitation are also changing
– 3:1 and DaNang lung– 1:1:1, 1:2 for blood/FFP/platelets
• Emergent availability of FFP
Holcomb et al. J of Trauma 2006 Feb ; 62 (2) :294-310
Gutierrez G, Reines D. Clinical Review: Hemorrhagic Shock. Crit Care. Apr 2004 8(5): 373-381.
Krausz M. Initial resuscitation of hemorrhagic shock. World J Emer Surg 2006 1:14.
Fluid Resuscitation
• Currently recommendations are still crystalloid (LR/ NS) as initial fluid
• Transfusion is not recommended unless there is FAILURE to respond to 2 liters of crystalloid WITH suspected hemorrhage– More studies accumulating that demonstrate that
transfusion except in the massive transfusion setting has significant morbidity and mortality
– Increased tolerance of anemia • Resurgence of Interest in Whole Blood for Massive
Transfusion
Holcomb et al. J of Trauma 2006 Feb ; 62 (2) :294-310
Gutierrez G, Reines D. Clinical Review: Hemorrhagic Shock. Crit Care. Apr 2004 8(5): 373-381.
Endpoints of Resuscitation
What does “Endpoints of Resuscitation” mean?
AMA?
Resident 80 hour work week?? “Ideal” Endpoint of Resuscitation
• Marker of the presence of SHOCK – at the earliest stages
• Ensures that resuscitation is complete – normalization of the endpoint
Endpoints of Resuscitation
• Severely Injured Trauma Patients- High risk for multiple organ dysfunction syndrome (MODS)
- Death
• Maximize Chances for Survival– treatment modalities – must focus on:
Resuscitation from shock- Rapid hemostasis - Appropriate fluid resuscitation
Endpoints of Resuscitation
• Shock - inadequate tissue oxygenation to meet tissue O2 requirements
• Leads to anaerobic metabolism – results in metabolic acidosis
• Depth and duration of shock – cumulative oxygen debt
Endpoints of Resuscitation
• Resuscitation is complete, when:1. Oxygen debt is repaid2. Tissue acidosis eliminated3. Normal aerobic metabolism is restored
Endpoints of Resuscitation
• Patients may appear to be adequately resuscitated based on normalization of vital signs
• --- But may have occult hypoperfusionand ongoing tissue acidosis
May lead to organ dysfunction and death
Use of “Endpoints” may allow early detection and reversal of
this state
Hemostasis – First!!!
Uncontrolled Hemorrhage
Fluid Resuscitation• No Fluid Resuscitation – may lead to death• Aggressive Fluid Resuscitation – may lead
to more bleeding – “pop the clot”• “Limited” (or “hypotensive” or “delayed”)
Fluid Resuscitation – may be beneficial
Uncontrolled Hemorrhage
Controversial – Aggressiveness of IVFs in hypotensive patient with suspected uncontrolled hemorrhage – before surgical control
• May increase amount and rate of bleeding• Uncorrected severe hypotension
- May lead to death- If TBI – Secondary brain injury - Risk of post-operative organ failure
Fluid Resuscitation in Uncontrolled Hemorrhage
• Shaftan, Surgery 1965; 58:851-856 – Dog model – aggressive fluid resuscitation with uncontrolled arterial bleeding, led to increased amount of bleeding
Fluid Resuscitation in Uncontrolled Hemorrhage
• Capone, J Am Coll Surg 1995;180:49-56 – Rat model – uncontrolled hemorrhage, attempts to achieve normal MAP – increased bleeding and mortality, while hypotensive resuscitation improved survival
• Several studies – Uncontrolled bleeding from spleen, there was increased bleeding and mortality – with vigorous infusion of crystalloids.
Fluid Resuscitation in Uncontrolled Hemorrhage
• Bickell, et al, October 1994 NEJM• “Immediate versus Delayed Fluid
Resuscitation for Hypotensive Patients with Penetrating Torso Injuries”
• Lower survival in patients who received fluid resuscitation before surgical control of bleeding, versus patients receiving delayed fluids in the OR (62% vs 70%)
Hypotensive Resuscitation during Active Hemorrhage: Impact on In-Hospital Mortality
Dutton, R., et al; Journal of Trauma, Vol. 52(6). June 2002. 1141-1146
• Clinical trial – patients with initial systolic BP < 90 mmHg – evaluated role of titration of the initial resuscitation fluid to a systolic BP lower than normal (systolic BP < 70 mmHg) vs normal (syst BP > 100 mmHg)
• Mortality same• Concluded – titration of initial fluid therapy in
hypotensive trauma patients to lower than normal BP – during active bleeding – did noteffect mortality
Conclusions – Resuscitation of Hypotensive Trauma Patients
• Aggressive fluid resuscitation – with uncontrolled hemorrhage – increases bleeding and mortality
• “Controlled hypotension” – may prevent worsening of bleeding associated with aggressive fluid resuscitation – while preventing cardiac arrest or organ failure – secondary to tissue hypoperfusion
• Optimal MAP may be 60-80 mmHg
Endpoints of Resuscitation Advanced Trauma Life Support (ATLS)
• Standard of Care – Markers of “successful”resuscitation include the restoration of NORMAL:
1. Blood Pressure2. Heart Rate3. Urine Output
> 0.5 cc/kg/hr – Adult > 1.0 cc/kg/hr – Child
• If these remain abnormal – clear that need further resuscitation
Classes of ShockClassClass Blood Blood
LossLossRespondResponderer
CNSCNS BPBP PulsePulse/RR/RR
UrineUrine TXTX
Class IClass I 750cc750cc
15%15%YesYes Slightly Slightly
anxiousanxiousNLNL <100<100 3030
cc/hrcc/hrIVFsIVFs
Class IIClass II 750750--1500cc1500cc
1515--30%30%
YesYes Mildly Mildly anxiousanxious
NLNL >100>100 2020--3030
cc/hrcc/hrIVFsIVFs
? blood? blood
Class IIIClass III 15001500--2000cc2000cc
3030--40%40%
Transient or Transient or nonnon--responderresponder
ConfuseConfused d AnxiousAnxious
Mod Mod decreasdecreaseded
>120>120 55--1515
cc/hrcc/hr
IVFsIVFs
BloodBlood
OperationOperation
Class IVClass IV >2000cc>2000cc
> 40%> 40%
NonNon--responderresponder
LethargiLethargicc
MarkedlMarkedly y decreasdecreaseded
>140>140 NegligNegligibleible
Rapid Rapid IVFsIVFs
BloodBlood
OperationOperation
Hypovolemic Shock
Rapid ResponseRapid Response Transient ResponseTransient Response No ResponseNo Response
VITAL SIGNSVITAL SIGNS Return to normalReturn to normal Transient Transient improvementimprovement
Recurrence of BP/HRRecurrence of BP/HR
RemainRemain
AbnormalAbnormal
EstimatedEstimated
Blood LossBlood Loss
MinimalMinimal
(10 (10 –– 20 %)20 %)
Moderate and Moderate and ongoingongoing
(20 (20 –– 40 %)40 %)
Severe Severe
( > 40 %)( > 40 %)
Need MoreNeed More
CrystalloidCrystalloid
LOWLOW HIGHHIGH HIGHHIGH
Need More Need More
BloodBlood
LOWLOW MODERATE to HIGHMODERATE to HIGH IMMEDIATEIMMEDIATE
Need Need Operative Operative InterventionIntervention
POSSIBLYPOSSIBLY LIKELYLIKELY HIGHLY HIGHLY
LIKELYLIKELY
Advanced Trauma Life Support (ATLS) –(Con’t)
• After normalizing the above parameters – up to 85% of severely injured trauma patients –have inadequate tissue oxygenation (occult hypoperfusion) – based on ongoing metabolic acidosis or gastric mucosal ischemia (compensated shock)
• ***Recognizing this state – with better “markers” – and rapid reversal – minimize risk of MODS or death
• Use of “endpoints” may allow early detection and reversal of this state
Endpoints of Resuscitation
•Global Endpoints •Regional (Organ-Specific) Endpoints
Global Endpoints
• Blood pressure• Heart rate• Urine output• Mental status• Capillary refill • Pulse Pressure• Base deficit/pH• Serum lactate levels• Oxygen delivery/consumption
Arterial Base Deficit
• Higher Base Deficit – associated with lower blood pressure on admission, greater blood loss, and greater fluid needs
• Normal range of “Base Deficit” – (- 3 to + 3mM)
• Mild (BD – 2-5), Moderate (BD – 6-14), Severe – BD > 14)
• Base deficit – correlates with mortality • BD > 6 – marker for severe injury
Arterial Base Deficit (con’t)
• Increasing base deficit – 2/3 ongoing blood loss
• Increase BD – instability, transfusions, coagulation abn, risk of death, length of stay, acute lung injury
• BD > 8; 25% mortality• BD > 15; 70% mortality• Serial Base Deficits – document clearing
Arterial Lactate
• Time to normalize lactate – important prognostic factor
• Normalized 24 hours – all survived• Normalized 24-48 hours – 25% mortality• Not normalized 48 hours – 86% mortality• Lactate > 2.5mM at 12 hours post-injury
predicted onset of multi-organ failure
• Not readily available in all institutions
Pulmonary Artery Catheter
• Commonly used in ICU setting• PCWP – approximates Left atrial pressure,
which approx. left ventricular end-diastolic pressure (LVEDP) – which reflects LVED Volume, which correlates with contractility
Pulmonary Artery Catheter
• Assumptions• Inconsistent relationship – between PCWP
and Cardiac Output – acute lung injury, high ventilator pressures, poor pulmonary compliance, and/or hemodynamically unstable
Esophageal Doppler Monitor (EDM)
• Small caliber Doppler ultrasound probe –esophagus – measures the mean velocity (Vm) of blood flow in descending aorta
• Cardiac output and preload assessment –regardless of the level of mechanical ventilation
• CO calculated by computer – using aortic diameter – estimated by nomogram
• Doppler waveforms – calculates flow time –measures cardiac preload and peak velocity –measures cardiac contractility
Invasive Monitoring
• Scalea (J. Trauma 1990 Feb; 30 (2): 129-134) – Instituted protocol for early invasive hemodynamic monitoring of high risk geriatric blunt trauma patients (severe injuries)
• Identified occult shock early • Optimized pts. - volume, inotropes, and
afterload reduction – as needed• Helped prevent MODS and death
Determinants of O2 Delivery
• Cardiac Output– HR X S.V.
• Arterial O2 Content = CaO2– [Hb x 1.39 x SaO2] + [PaO2 x 0.0031]
• DO2 (O2 Delivery)– C.O. x CaO2 x 10
Oxygen Delivery
• Shoemaker – evaluated high risk surgical patients who survived – found they had significantly higher O2 delivery and cardiac index (CI - > 4.5 L/min/m2); (O2 delivery was > 600 mL/min.m2) and (oxygen consumption > 170 mL/min.m2)
• Goals for Resuscitation – to improve survival • Maximizing O2 delivery – volume loading,
dobutamine infusion if necessary, and blood transfusions to hemoglobin of 14
• Supranormal levels of CI, DO2, and VO2 – improvement in survival and decrease in organ failure rates
• If did not reach goals by 12 hours – increased risk of MODS
Oxygen Delivery (con’t)
• Durham, Journal of Trauma 1996;41 -Resuscitation to O2 delivery and consumption parameters defined by Shoemaker - did not improve rate of MODS or death
• ***Predictors of outcome – not endpoint of resuscitation
Mixed Venous Oxygen Saturation (SvO2)
• Reflects adequacy of O2 delivery to tissues – in relation to global tissue O2 demands
• Normal – SvO2 = 75%• Normal – PvO2 = 40 mmHg• Central venous oxygen saturation = ScvO2• If ScvO2 < 70% - tissue hypoperfusion
Regional Endpoints
• Gastric tonometry – gastric ischemia• Tissue oxygen monitoring• Brain oxygen monitoring• Near Infrared Spectroscopy (NIRS) –
regional cellular oxygenation
Gastric Tonometry
• If systemic perfusion decreases – shunting from some organs (skin, muscle, kidneys, and gut) to preserve flow to brain and heart
• If the sub-clinical ischemia to organs could be identified – these are the patients that need additional resuscitation despite seemingly normalized vital signs
Gastric Tonometry
• Gastric tonometry (tonometric nasogastric tube – gas permeable silastic balloon filled with saline as a tonometer) – based on the finding that tissue ischemia leads to an increase in tissue PCO2, and subsequent decrease in tissue pH.
• Gastric Mucosal pH• Intramucosal pH (pHi) – calculated based
on Henderson-Hasselbach equation
Gastric Tonometry
• pHi – correlates with sepsis score• pHi < 7.32 – mortality rate of 37%• pHi > 7.32 – all survived• pHi < 7.32 – good predictor of MODS and
mortality• Technological limitations – manual
technique – using semi-permeable balloon is cumbersome
Near Infrared Spectroscopy (NIRS)
• Method of monitoring hemoglobin O2 saturation in tissue (StO2)
• Non-invasive and continuous method for monitoring adequacy of resuscitation – in terms of normalizing tissue oxygenation
• Skeletal muscle StO2 (transcutaneous probe) –tracks systemic O2 delivery, with improved StO2 with resuscitation
• Potential for NIRS to monitor tissue perfusion and guide resuscitation
• What should be done on a daily basis? • Multi-system injured trauma patient –
involved in MVC – Hypotensive at scene, arrives in the ED in shock, and admitted to the OR and/or ICU
• How should we resuscitate and monitor the patient’s response, to avoid MODS and death???
• Pre-hospital, ED, OR and ICU
Discussion
Pre-Hospital Endpoints
• Blood Pressure (MAP) – Dynamap- Monitor continuously- Maximize BP for patients with brain injury- Resuscitate to lower limits of normal with penetrating injuries
• Pulse Oximetry - Oxygen saturation – to optimize in pre-hospital setting
Emergency Department Endpoints
• Monitor response to resuscitation – ATLS • ABGs – Base Deficit – severity of shock
and adequacy of resuscitation • Lactate levels
OR and ICU
• Ensure clearance of Base Deficit• Pulmonary Artery Catheter (PCWP)• Organ Specific Resuscitations – (ie- TBI)• Tissue oxygen and metabolic indicators• Near Infrared Spectroscopy (NIRS)• Esophageal Doppler monitoring
What is the “True”Endpoint of
Resuscitation????
Case Presentation
• JW is a 53 year old AAM• Found down less than 12 blocks from SLH after
sustaining a GSW to the abdomen at approx 2046• 2058 EMS arrived on scene• 2103 Pt with agonal respirations and unresponsive
orally intubated in the field, 2 16G IVs placed• VS recorded by EMS
• 2108 60/40 60 6 84% • 2112 54/38 118 18 86%
Case Presentation
• 1800 mL in crystalloid given prior to arrival • 2112 Arrival as Level I Activation
– 108/35 HR 77
– 72/42 HR 68
– 102/77 HR 63
– 30/11 HR 63
• Pt received additional 4 liters crystalloid and one unit PRBC in bay
Case Presentation
• After the initial drop in SBP, FAST exam was performed, NEG
• Abd soft, non-distended• Wound was locally explored appearing to track
superficially • CXR, KUB, Central lines, Labs, and Foley were obtained.
Pt also received Ancef and Tetanus.– 2 cm metallic fragment at level of L1/L2 and two smaller
fragments lower in abd• 2135 After the second drop in SBP the pt was taken
emergently to the OR
Case Presentation
• 2140 Hb 6.7 Plts 210 INR 1.4 CO2 16 ICa 4.2 • CellSaver was operational prior to skin incision• Massive amount of intrabdominal blood present, greater
than 3.5 liters • Aortic tamp required to maintain a blood pressure and
pulse while on 3 pressors and receiving massive transfusion
• Right colon perforation, hilar injury to the right kidney
Case Presentation• 2240 6.98 / 56 / 322 / 12.4 / -18.3
– Lactate 6.8, ICa 5.5, Hb 8.8
• 2228 INR 6.3 PT 58.3 PTT >200 Plt 44 FIBRINOGEN 47
• 2320 7.06 / 57 / 378 / 15.5 / -13.3 – Lactate 6.8, ICa 2.1, Hb 4.8
• 0001 6.94 / 75 / 344 / 15.2 / -15.7– Lactate 7.7, ICa 2.5, Hb 6.1
• Damage control was performed and the pt continued to ooze continuously
Case Presentation
• Pt was transfused with – 9 units PRBCs in OR– 1 unit PRBCs in ER– 1525 mL of recovered PRBCs from CellSaver– 4 units FFP – One single donor unit platelets
• Additional agents to pressors and antibiotics included – 4 liters crystalloid– 2 grams of Calcium chloride– 3 amps of Sodium bicarbonate
Case Presentation
• Ultimately when all visible sources of bleeding were controlled hemostatic agents were employed – Gel Foam – Evisel– Thrombin – Novo 7, ordered, not administered
• The patient had no sustainable blood pressure without aortic tamp in place and continued to ooze
• 0002 The patient was declared dead
17 y/o Male – Bicycle vs Car
Scene – 2300 • Found 50 feet from bicycle• GCS – 3 • BP – 80/palp• Pulse – 72 • Deformity of right femur
Management at Scene
Scene – Tx
1. Intubation2. Establish IV 3. IVFs – 750 cc4. Splint femur fracture
ED Evaluation – 2030
• Temp – 36.5• BP – 139/91• Pulse – 87• GCS – 6 • 97% O2 sats• IVFs/Urine = 1000cc/150cc• Hb – 12.6
ED Management
Priorities
• Avoid hypoxemia and hypercarbia –Intubation and ventilation
• Maintain adequate perfusion –“Euvolemia”
• Avoid secondary brain injury• Disability – evaluate for need for
craniotomy;
Resuscitation
• Admit ED – 2030• Volume Resuscitation – ED = 1000cc;
Urine output – 150cc• ED – 2050 – BE = (-7.0)• ICU – 2300 – BE = (-5.8)• ICU – 0254 – BE = (-5.7)• Urine Output ICU – 50cc/hr• Hb – 10.0 (0400)
PID # 1 PID # 1
OR for Femur Fracture – 0800 PID # 1
• 0900 – 1 liter LR• 0925 – 60/20• 0945 – 70/25 1 liter LR• 0950 – 70/25 Phenylephrine 100 mcg• 0955 – 70/20 Phenylephrine 100 mcg• 1000 – 75/45• 1005 – 90/40• 1025 – 100/40• Total IVFs – 4300 ml• EBL – 150cc• Urine – 230 ml
PID # 1 - Anesthesia Record
Hospital Course
• Rehab – PID # 10
Base Deficits
• 0515 - 10.4• 0815 - 7.4• 1004 - 8.5• 1454 - 4.3• 2014 - 3.0• 2157 - 3.2• 2351 - 2.6• 0232 - 0.8
Conclusions
• The complexity of simultaneous resuscitation and obtaining surgical control of massive hemorrhage cannot be underestimated.
• Massive transfusion protocols • Calcium and Cryopreciptate • Ideal resuscitation as a moving target• Teamwork and Communication
References
• Cotran, R., Kumar, V., Collins,T. (1999). Robbins pathologic basis of disease (6th edition). Philadelphia, PA: W.B. Saunders Company.
• Donohoe Dennison, Robin (2000). PASS CCRN! (2nd edition). Missouri: Mosby, Inc
• Gaieski, D., Parsons, P., Wilson, K. Shock in adults: Types, presentation, and diagnostic approach. UpToDate 2008.
• Todd, J., Wesley (1997). The Cardiovascular Review Book for Invasive Cardiovascular Technology Vol I.: Anatomy, Physiology & Pathology.
Self Published by Cardiac Self Assessment• Todd J., Wesley (1997). The Cardiovascular Review Book for Invasive
Cardiovascular Technology Vol II.: Invasive Diagnostic Techniques. Self Published By Cardiac Self Assessment.
• White, K. (2003). Fast facts for adult critical care. Mobile, AL: Kathy White learning systems.
Death?
Total
Respond‐
ing
NC 17 17 100.0% 10.6%
NE 41 38 92.7% 23.8%
NW 20 19 95.0% 11.9%
SC 49 48 98.0% 30.0%
SE 20 19 95.0% 11.9%
SW 20 19 95.0% 11.9%
Total 167 160 95.8% 100.0%
Response Totals by EMS Type
Total %
37 22.8%
117 72.2%
8 4.9%
162 100.0%
Response Totals by EMS Staffing
Total %
54 32.9%
36 22.0%
74 45.1%
164 100.0%
44 27.7%
91 57.2%
23 14.5%
1 0.6%
159 100.0%
33 20.9%
84 53.2%
38 24.1%
3 1.9%
158 100.0%
*Five services were out of state, four of which responded. These
services are excluded from tables showing regional counts, but are
included in all other results.
Staff completing the PHTLS training programs
are better prepared to care for trauma
patients.
1. Strongly Agree
2. Agree
3. Neutral
4. Disagree
This service is better able to handle trauma
cases as a result of staff completion of PHTLS
training.
EMS Trauma Education Survey
Response Totals by Region
Region
# of EMS Services*
Response
Rate
% of All
Respond‐
ing
c) Paid and Vol.
Total
Total
Total
1. Strongly Agree
2. Agree
3. Neutral
4. Disagree
a) Type I
Type of EMS Service
a) Paid only
b) Volunteer only
Staffing of EMS
Total
c) Type V
b) Type II
Respondent % by RegionNC, 10.6%
NE, 23.8%
NW, 11.9%
SC, 30.0%
SE, 11.9%
SW, 11.9%
Usefulness of Training
27.7%
0.6%
53.2%
24.1%
1.9%
57.2%
14.5%
20.9%
0.0% 25.0% 50.0% 75.0% 100.0%
1. Strongly
Agree
2. Agree
3. Neutral
4. Disagree
Staff Better Prepared with PHTLS Service Better Prepared with PHTLS
Response Rates by Region
100.0%
92.7%
95.0%
98.0%
95.0%
95.0%
0.0%
25.0%
50.0%
75.0%
100.0%
NC NE NW SC SE SW
Respondent % by EMS
Type a)
Type
I,
22.8%
b)
Type
II,
72.2%
c)
Type
V,
4.9%
Respondent % by
Staffinga)
Paid
only,
32.9%
b)
Volun
teer
only,
22.0%
c)
Paid
and
Vol.,
45.1%
Page 1 of 2
EMS Trauma Education Survey
Attendants, including all First Responders, EMTs, and Paramedics, full and PT, providing care in your service.
Region
NC
NE
NW
SC
SE
SW
Total
371 179
1300 516 784 60.3%
4560 1533 3027 66.4%
294 61.5%
398 90 308 77.4%
192 51.8%
478 184
1638 492 1146 70.0%
375 72 303 80.8%
Total Number # With PHTLS Training # Needing Training
% Needing
Training
# Needing PHTLS Training
1146
303 308
784
192294
0
200
400
600
800
1000
1200
1400
NC NE NW SC SE SW
% Needing PHTLS Training
80.8% 77.4%
60.3%70.0%
51.8% 61.5%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
NC NE NW SC SE SW
Barriers to Attendance (N=164)
38.4%
19.5%
57.3%
1.2%
20.1%
7.3%
36.6%47.6%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Facility Space Cost of
Hosting
Lack of
Instructors
Staffing
Coverage
Staff Interest Cost of
Sending Staff
Getting Time
Off
Other
Page 2 of 2
Total*
Respond‐
ing
NC 13 13 100.0% 10.2%
NE 33 33 100.0% 26.0%
NW 18 18 100.0% 14.2%
SC 31 31 100.0% 24.4%
SE 14 14 100.0% 11.0%
SW 18 18 100.0% 14.2%
Total 127 127 100.0% 100.0%
Total %
Com‐
bined %
43 34.7%
44 35.5%
14 11.3%
23 18.5%
124 100.0% 100.0%
90 72.0%
35 28.0%
125 100.0%
24 40.7%
23 39.0%
12 20.3%
59 100.0%
Hospital Trauma Education Survey
Staff completing the ATLS and/or TNCC are
better prepared to care for trauma patients.
Region
Response
Rate
Hospital licensed
beds
a) 0‐24 beds
b) 25‐49 beds
*Represents all Critical Access Hospitals, and acute care facilities providing
trauma services.
70.2%
29.8%
This hospital is better able to handle trauma
cases as a result of participating in RTTDC
training.*
Total
% of All
Respond‐
ing
Response Totals by Region
a) Strongly Agree
*65 hospitals indicated that they had not yet completed RTTDC training, so they were excluded from the response calculations for this question.
# of Hospitals
a) Strongly Agree
b) Agree
Response Totals by Licensed Bed Count
c) 50‐100 beds
d) >100 beds
Total
b) Agree
c) Neutral
Total
Hospital licensed bedsa) 0‐24
beds,
34.7%
b) 25‐49
beds,
35.5%
c) 50‐100
beds,
11.3%
d) >100
beds,
18.5%
Respondent % by RegionNC, 10.2%
NE, 26.0%
NW, 14.2%SC, 24.4%
SE, 11.0%
SW, 14.2%
Usefulness of Training
72.0%
28.0%
40.7%
39.0%
20.3%
0.0% 25.0% 50.0% 75.0% 100.0%
a) Strongly
Agree
b) Agree
c) Neutral
Staff Better Prepared with ATLS/TNCCHospital Better Prepared with RTTDC
Response Rates by Region
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
0.0%
25.0%
50.0%
75.0%
100.0%
NC NE NW SC SE SW
Role in the organization for person
completing the survey (N=127)Chief Executive
Officer
(CEO), 7.9%
Chief Nursing
Officer
(CNO), 37.8%
Emergency
Department
Director,
11.0%
Emergency
Department
Nurse
Manager,
17.3%
Emergency
Department
Staff Nurse,
0.8%
Other, 25.2%
Page 1 of 3
Hospital Trauma Education Survey
Physicians, PAs, and ARNPs, full and part‐time, providing coverage in ED as primary care provider
Region
NC
NE
NW
SC
SE
SW
Total
RNs and LPNs, full and part‐time, providing nursing care in ED
Region
NC
NE
NW
SC
SE
SW
Total
925
30
157
28
126
32
425
81
52
345
48
81
76
253
89
60.5%
127
37 41.6%
Total Number # With TNCC Training
54.1%
51
188
63.0%
# Needing Training % Needing Training
49
500
54.5%
63.2%
50.2%
938 641 297 31.7%
202 111 91 45.0%
238 155 83 34.9%
166 28.6%
201 136 65 32.3%
581 415
279 143 136 48.7%
Total Number # With ATLS Training # Needing Training % Needing Training
2439 1601 838 34.4%
# Needing ATLS Training
51
188
48 37 49
127
0
50
100
150
200
250
300
NC NE NW SC SE SW
% Needing ATLS Training
63.0%54.5%
63.2%
41.6%
60.5%50.2%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
NC NE NW SC SE SW
# Needing TNCC Training
91 83
166136
297
65
0
50
100
150
200
250
300
NC NE NW SC SE SW
% Needing TNCC Training
45.0%
31.7% 34.9%
28.6%
48.7%
32.3%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
NC NE NW SC SE SW
Page 2 of 3
Hospital Trauma Education Survey
Barriers to Attendance (N=127)
15.7%
38.6%
15.7%
69.3% 65.4%
11.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Facility Space Cost Lack of
Instructors
Staffing
Coverage
Staff Interest Other
Page 3 of 3