• Cambridge Damage Control Symposium

    by Alan Batt. Last modified: 25/11/14

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    The Cambridge Damage Control Symposium was held in the Mohammed Bin Rashid Academic Medical Center in Dubai Healthcare City on the 24th November 2014. I was kindly sent by National Ambulance LLC as a member of their Clinical Education Team, and they have allowed me to produce this report for both staff of National Ambulance and for the FOAM community.

    Damage control resuscitation is a term used to encompass the range of strategies focused on balancing haemostatic resuscitation, permissive hypotension, lung protection, wound protection and neuro-protection whilst maintaining tempo and critical organ and system support.

    In this symposium, experienced members of pre-hospital and emergency department trauma teams looked at current damage control resuscitation strategies and discussed the practical considerations in implementing them.

    The day started with Dr. Rod McKenzie, Consultant in Emergency Medicine and director of the Major Trauma Centre at Addenbrooke Hospital, and prehospital physician with London Air Ambulance.

     

    Components of Damage Control Resuscitation

    dcs

    A – Airway Management

    The day followed the ATLS standard A-B-C-D-E approach to Damage Control Resuscitation. First up was Airway. Some of the key points from this talk were:

    Decisions for prehospital anaesthesia are not based on GCS criteria! Candidates for perhospital anaesthesia and airway control are:

    1. Failure to maintain the airway
    2. Failure to protect
    3. Failure to oxygenate
    4. Failure to ventilate
    5. Expected clinical course

    Always weigh up the risk of anaesthesia versus the risk of none.

    Is it an airway problem v breathing problem?

    • Near death (agonal respirations/cardiac arrest/anticipated laryngoscopy) = crash intubation
    • Not near death = Assess for difficult DL or BVM. If difficult then reconsider risk/benefit

    There is no such thing as a failed intubation…it is failed laryngoscopy.

    BVM is important for rescue of airway!

    • Plan A – RSI > DL > Bougie/ET
    • Plan B – rescue ventilation
    • Plan C – rescue oxygenation
    • Plan D – Surgical

    Ref Difficult Airway Society (http://www.das.uk.com/files/rsi-Jul04-A4.pdf)

    Crash intubation = facemask, BVM to provide oxygenation. Equipment dump if possible.

    dump

    Failed plan A or B = go to plans C/D

    Sux useful if near-death and patient has increased muscle tone/trismus.

    Consider primary surgical airway in difficult airway prediction (max-fax injuries, access difficult)

    RSI

    1. Preparation
    2. Preoxygenation
    3. Pretreatment
    4. Paralysis with induction
    5. Positioning
    6. Placement with proof
    7. Postintubation management

    Is the patient LEMON positive?

    lemon

    Don’t forget adequate preoxygenation! Desaturation occurs faster in different patient populations.

    graph

    Time to Desaturation for Various Patient Circumstances. Source: From Benumof J, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997;87:979.

    • Optimise the airway!
    • Complete checklist – “to err is human”
    • Then proceed.
    • Can use ketamine for induction (2mg/kg normal; 1mg/kg in frail,shocked,elderly)
    • NB – sux is based on actual body weight
    • Don’t keep it to yourself, verbalise what you can see under DL
    • Cannot understate capnography!!
    • Movement is high risk – increasingly indefensible to not have capnography, even on SGAs
    • If 1st attempt failed, don’t just do the same again!

     

    B – Ventilatory Support & Lung Protection

    ATLS Deadly Dozen!

    Prevent Lung Injury

    • Reduced Expansion
    • Atelectasis
    • Pain & narcotics
    • Aspiration
    • SIRS
    • Emboli
    • Increased work of breathing
    • Pulmonary haemorrhage
    • Excess fluid administration
    • Structural damage

    What is lung protection?

    • Optimise O2 delivery
    • Treat
    • Minimise further injury

    Ventilation – alveolar mechanics videos

    Normal: http://www.youtube.com/watch?v=Om8wkwWInPM

    Low Tidal Volume ventilation: http://www.youtube.com/watch?v=eK19izkSQZo

    High Tidal Volume Ventilation: http://www.youtube.com/watch?v=M9uI9xKWW-E

    Injured lungs = baby lungs. Any ventilation is harmful

    Decrease volume, increase rate, increase FiO2, +/-PEEP

    e.g. 6ml/kg; 12bpm; 0.6-1.0 FiO2; PEEP 5

    • Have a low threshold for open thoracostomy.
    • Intubated, PPV, thoracic injury = open thoracostomy.
    • Classic ATLS signs of tension pneumothorax are uncommon!
    • Differentiate spontaneous respiration v ventilated pneumothorax
    • We miss flail segments…around the back!
    • Humidification and other ARDS approaches can reduce lung injury

     

    C – Circulatory Support

    We’re relearning the lessons of war.

    Haemostatic resuscitation – preserve blood, not replace it!

    1. Stop compressible bleeding
    2. Reduce non-compressible bleeding
    3. Prevent coagulopathy
    4. Administer TXA
    5. Consider risk/benefit of transfusion
    6. If transfusing then balanced RBC:FFP:Plat on a 1:1:1 ratio

    Don’t forget the bleeding basics!

    • Direct pressure!
    • Gauze
    • Pressure dressing
    • TQ
    • Haemostatic agent

    Basic equipment, aggressive search for bleeding & show no mercy to blood loss!

    Celox – pack the wound

    • Most bleeding patients are already coagulopathic or are at high risk of coagulopathy
    • Hypothermia, blood loss etc – stop!
    • Assume coagulopathy – manage before labs
    • Give no fluids that do not clot or carry oxygen!

    Permissive Hypotension

    In a small subset of patients permissive hypotension may be useful. MTP activated (just in case), keep shocked until OR. Penetrating trauma mostly. If conscious on arrival – always watching perfusion (mentation)

    Goals are not always achievable however. There is no literature on permissive hypotension in blunt trauma.

    Tube thoracostomy if bleeding – insert drain; we should be auto-transfusing this blood back in!

    TXA

    CRASH2 Trial: 274 hospitals, 40 countries, 20000+ pts.

    • 3hrs
    • 32% reduction in RIP

    Blood – pre-alert or use if you have! MTP needs prealert!

    D – Neuroprotection

    Single hypotensive or hypoxic episode = 2 x RIP

    Goal is the prevention of 2nd degree brain injury

    Maintain CPP!

    4 Hs of secondary injury

    • Hypoxia
    • Hypotension
    • Hyper/hypocarbia
    • Hypothermia

    Goals

    1. SpO2 ~ 92%.
    2. MAP > 80 mmHg (to maintain CPP/CBF)
    3. Low N Co2 4-4.5kPa/35-45mmHg. Watch the ETCO2. Mortality >if ETCO2 outside N. If unequal pupils, hyperventilate to ETCO2 of 3kPa
    4. Maintain temp 35-37C
    5. Ideally 4 hrs from injury to surgery – actually ASAP!
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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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