Adult Trauma Advances in (sometimes they are little adults) - - PDF document

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Adult Trauma Advances in (sometimes they are little adults) - - PDF document

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3/7/2018 Adult Trauma Advances in (sometimes they are little adults) Pediatrics Alisa McQueen MD, FAAP, FACEP Alisa McQueen MD, FAAP, FACEP Associate Professor of Pediatrics Associate Professor of Pediatrics The University of Chicago The

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Adult Trauma Advances in Pediatrics

Alisa McQueen MD, FAAP, FACEP Associate Professor of Pediatrics The University of Chicago

(sometimes they are little adults)

Alisa McQueen MD, FAAP, FACEP Associate Professor of Pediatrics The University of Chicago

I have no re le vant financ ial re latio nships to disc lo se . T XA

Who is b le e ding ? Ho w muc h a nd wha t kind o f vo lume ? Ca n we me dic a lly slo w do wn b le e ding ?

T XA

F AST e xa mina tio n Ho w muc h a nd wha t kind o f vo lume ? Ca n we me dic a lly slo w do wn b le e ding ?

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T XA

F AST e xa mina tio n Da ma g e Co ntro l Re susc ita tio n Ca n we me dic a lly slo w do wn b le e ding ?

T XA

F AST e xa mina tio n Da ma g e Co ntro l Re susc ita tio n T ra nse xa mic Ac id (T XA)

T XA

Wha t is F AST a nd why do we do it?

I s the re b lo o d in the a b do me n?

Unsta b le DPL Sta b le CT sc a n I nva sive Ra d ia tio n

F AST : F

  • c use d Asse ssme nt with

So no g ra phy in T ra uma

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F AST : F

  • c use d Asse ssme nt with

So no g ra phy in T ra uma Adults: sta nda rd o f c a re K ids? F AST : F

  • c use d Asse ssme nt with

So no g ra phy in T ra uma Adults: sta nda rd o f c a re K ids: 10-15% F AST in Pe dia tric T ra uma

Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32.

Sub-analysis of children with blunt abdominal trauma 20 PECARN EDs

F AST in Pe dia tric T ra uma

Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32.

Ho w suspic io us a re yo u fo r intra - a b do mina l injury?

  • F

re q ue nc y o f F AST

  • F

re q ue nc y o f CT

  • Misse d intra a b do mina l injury

Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32.

Ve ry lo w (<1%) L

  • w

(1-5%) Mo de ra te (6-10%) Hig h (11-50%) Ve ry hig h (>50%)

11 % 13 % 20 % 23 % 30 %

Ra te o f F AST inc re a se d a s the suspic io n fo r intra - a b d o mina l injury inc re a se d

Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32.

Ve ry lo w (<1%) L

  • w

(1-5%) Mo de ra te (6-10%) Hig h (11-50%) Ve ry hig h (>50%)

11 % 13 % 20 % 23 % 30 % 1.01 0.84 0.86 0.98 0.98

R

RR o f CT de c re a se d sig nific a ntly fo r lo w- mo de ra te suspic io n injurie s whe n F AST pe rfo rme d

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Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32.

Ha d to e xc lude b e c a use no t e no ug h F AST pe rfo rme d Whe n e xc lude d site # 1, e ffe c t o f F AST

  • n CT

de c re a se d

F AST in Pe dia tric T ra uma

Ca lde r B e t a l. F

  • c use d Asse ssme nt with So no g ra phy fo r T

ra uma in c hildre n with b lunt a b do mina l tra uma : a multi-institutio nal a na lysis. J T ra uma Ac ute Ca re Surg 2017;83:218-224.

All c hildre n < 16 with b lunt a b do mina l tra uma F AST / CT / pro c e dure s a t the disc re tio n o f tre a tme nt te a m F AST c o mpa re d with no F AST

F AST in Pe dia tric T ra uma

Ca lde r B e t a l. F

  • c use d Asse ssme nt with So no g ra phy fo r T

ra uma in c hildre n with b lunt a b do mina l tra uma : a multi-institutio nal a na lysis. J T ra uma Ac ute Ca re Surg 2017;83:218-224.

2188 pa tie nts 37.9% F AST (mo re like ly with MVC, le ss like ly with fa lls o r a ssa ult)

F AST in Pe dia tric T ra uma

Ca lde r B e t a l. F

  • c use d Asse ssme nt with So no g ra phy fo r T

ra uma in c hildre n with b lunt a b do mina l tra uma : a multi-institutio nal a na lysis. J T ra uma Ac ute Ca re Surg 2017;83:218-224.

Gra de 3+ live r/ sple e n injury I ntra -a b do mina l injury re q uiring inte rve ntio n 69 % ha d ne g a tive F AST 56 % ha d ne g a tive F AST

Se nsitivity a nd spe c ific ity o f pe dia tric F AST hig hly va ria b le

F AST in Pe dia tric T ra uma T ria l

Ho lme s JF e t a l. E ffe c t o f Ab do mina l U ltra so und o n Clinic a l Ca re , Outc o me s, a nd Re so urc e U se Amo ng Childre n with Blunt T

  • rso T

ra uma . A Ra ndo mize d Clinic a l T ria l. JAMA 2017;317:2290-2296.

Sta b le c hildre n with b lunt to rso tra uma ra ndo mize d sta nda rd tre a tme nt vs F AST Suspic io n fo r intra a b do mina l injury b e fo re / a fte r F AST CT a t tre a ting te a m disc re tio n

Ho lme s JF e t a l. E ffe c t o f Ab do mina l U ltra so und o n Clinic a l Ca re , Outc o me s, a nd Re so urc e U se Amo ng Childre n with Blunt T

  • rso T

ra uma . A Ra ndo mize d Clinic a l T ria l. JAMA 2017;317:2290-2296.

975 c hildre n 465 No F AST 460 F AST 52 % CT 54 % CT No diffe re nc e in CT ra te s No diffe re nc e in misse d injurie s No diffe re nc e in le ng th o f sta y

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Sho uld we a b a ndo n F AST in kids? Sho uld we a b a ndo n F AST in kids? Unsta b le kids we re no t inc lude d CT

  • b ta ine d a t disc re tio n o f the

pro vide rs Ma yb e we ne e d to do it mo re

Me na ke r J e t a l. U se o f the F AST e xa mina tio n a nd its impa c t o n a b do mina l c o mpute d to mo g ra phy use in he mo dyna mic a lly sta b le c hildre n with b lunt to rso tra uma . J T ra uma Ac ute Ca re Surg . 2014;77(3):427-32.

Ma yb e we ne e d to do it b e tte r

Bre nke rt T E e t a l. Pe rito ne a l fluid lo c a liza tio n o n F AST e xa mina tio n in the pe dia tric tra uma pa tie nt. Ame ric a n Jo urna l o f E me rg e nc y Me dic ine 2017;35:1497-99

T XA

Damage Control Resuscitation and Permissive Hypotension

“The Lethal Triad”

Hypothermia Acidosis Coagulopathy

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Da ma g e Co ntro l Surg e ry

  • 1. Co ntro l he mo rrha g e
  • 2. De c o nta mina te

Da ma g e Co ntro l Re susc ita tio n

  • 1. Pe rmissive hypo te nsio n
  • 2. E

a rly b lo o d pro duc ts o ve r sa line “I f the pre ssure is ra ise d b e fo re the surg e o n is re a dy to c he c k a ny b le e ding tha t ma y ta ke pla c e , b lo o d tha t is so re ly ne e de d ma y b e lo st.’ ’

  • WB Ca nno n

US Army Surg e o n 1918

WB Ca nno n. T he pre ve ntive tre a tme nt o f wo und sho c k. JAMA 1918;70:618-621.

Re tro spe c tive study o f a dults with pe ne tra ting tra uma a nd hypo te nsio n ma na g e d with DCR a nd DCS

Duke MD e t a l. Re stric tive fluid re susc ita tio n in c o mb ina tio n with da ma g e c o ntro l re susc ita tio n: time fo r a da pta tio n. J T ra uma Ac ute Ca re Surg 2012;73:674-678.

Sta nda rd fluid (150+ c rysta llo id) Re stric te d fluid (<150 ml c rysta llo id)

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Duke MD e t a l. Re stric tive fluid re susc ita tio n in c o mb ina tio n with da ma g e c o ntro l re susc ita tio n: time fo r a da pta tio n. J T ra uma Ac ute Ca re Surg 2012;73:674-678.

Sta nda rd fluid (a vg 2757ml) Re stric te d fluid (a vg 129ml) Mo rta lity in OR: 32% Mo rta lity in OR: 9% Mo rta lity in I CU: 5% Mo rta lity in I CU: 12% Ove ra ll mo rta lity: 37% Ove ra ll mo rta lity: 21% Hydro sta tic pre ssure ma y disrupt c lo ts Dilutio n o f c o a g ula tio n fa c to rs wo rse ns b le e ding I nfla mma to ry c a sc a de c o ntrib ute s to o rg a n fa ilure Blo o d vo lume va rie s b y a g e . I nfa nts: 90 – 100 c c / kg Yo ung c hildre n: 70 – 80 c c / kg Ado le sc e nts: 60– 65 c c / kg Childre n c a n lo se up to 45% o f the ir b lo o d vo lume b e fo re b e c o ming hypo te nsive . Childre n with tra uma tic b ra in injury ma y b e hypo te nsive . L imit iso to nic fluids a nd g ive b lo o d e a rly We do n’ t kno w wha t the ta rg e t b lo o d pre ssure sho uld b e We do n’ t kno w wha t the g o a ls in pe dia tric s sho uld b e

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T XA

T ra ne xa mic Ac id (T XA)

T XA

va sc ula r injury during surg e ry a c tiva te s c o a g ula tio n F ib rino lysis a nd c lo t b re a kdo wn

T XA

De c re a se s ne e d fo r tra nsfusio n b y 1/ 3

T XA

va sc ula r injury during surg e ry a c tiva te s c o a g ula tio n F ib rino lysis a nd c lo t b re a kdo wn

T XA

Co uld it wo rk fo r tra uma ?

Effects of TXA on death, vascular occulsive events, and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010;376:23-32.

CRASH-2

sic k tra uma pa tie nts

SBP < 90 HR > 110 Risk fo r sig nific a nt b le e ding

T XA Pla c e b o Prima ry o utc o me : de a th within 4 we e ks in ho spita l

CRASH-2

20,211 tra uma pa tie nts

SBP < 90 HR > 110 Risk fo r sig nific a nt b le e ding

T XA 10,096 Pla c e b o 10,115

274 ho spita ls 40 c o untrie s

14.5% mo rta lity fro m a ll c a use s 16% mo rta lity fro m a ll c a use s

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3/7/2018 9

CRASH-2

20,211 tra uma pa tie nts

SBP < 90 HR > 110 Risk fo r sig nific a nt b le e ding

T XA 10,096 Pla c e b o 10,115

274 ho spita ls 40 c o untrie s

4.9% mo rta lity fro m b le e d ing 5.7% mo rta lity fro m b le e d ing

CRASH-2 sub -a na lysis

T XA 10,096 Pla c e b o 10,115 4.9% mo rta lity fro m b le e d ing 5.7% mo rta lity fro m b le e d ing

  • 1. T

ime fro m injury (<1, 1-3, >3h)

  • 2. Se ve rity (SBP <75, 76-89, >89)
  • 3. GCS (3-8, 9-12, 13-15)
  • 4. T

ype o f injury (pe ne tra ting / b lunt)

CRASH-2 sub -a na lysis

  • 1. T

ime fro m injury (<1, 1-3, >3h)

  • 2. Se ve rity (SBP <75, 76-89, >89)
  • 3. GCS (3-8, 9-12, 13-15)
  • 4. T

ype o f injury (pe ne tra ting / b lunt)

CRASH-2 sub -a na lysis

  • 1. T

ime fro m injury (<1, 1-3, >3h)

  • 2. Se ve rity (SBP <75, 76-89, >89)
  • 3. GCS (3-8, 9-12, 13-15)
  • 4. T

ype o f injury (pe ne tra ting / b lunt) T he so o ne r T XA g ive n, the stro ng e r the b e ne fit. I f g ive n a fte r 3 ho urs, inc re a se d risk o f thro mb o tic e ve nts.

Wha t do we kno w a b o ut T XA in kids? Wha t do we kno w a b o ut T XA in kids?

Co a g ula tio n c a sc a de is the sa me b y a b o ut a g e 1 ye a r Sa fe use in e le c tive surg e ry (c a rdia c , sc o lio sis, c ra nio fa c ia l)

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SLIDE 10

3/7/2018 10 T XA use in U.S. Childre n’ s Ho spita ls

36 ho spita ls 2009-2013 T XA use in c hild re n < 18 ye a rs 64% c a rdio tho ra c ic surg e ry 18% sc o lio sis 3.6% c ra nio fa c ia l 14% o the r

0.3% tr auma

Nishijima D e t a l. T ra ne xa mic a c id use in US c hildre ns ho spita ls. J E me rg Me d 2016;50:868-74.

Pe dia tric T XA in c o mb a t se tting

Re tro spe c tive re vie w o f T XA use in c hild re n < 18 with tra uma in Afg ha nista n 766 c hildre n Me a n a g e 11 88% ma le 73% pe ne tra ting injury

E c ke rt MJ e t a l. T XA a dministra tio n to pe dia tric tra uma pa tie nts in a c o mb a t se tting (PE D- T RAX).J T ra uma Ac ute Ca re Surg 2014;77:852-858.

Pe dia tric T XA in c o mb a t se tting

Re tro spe c tive re vie w o f T XA use in c hild re n < 18 with tra uma in Afg ha nista n 9% re c e ive d T XA T e nde d to b e sic ke r Whe n c o ntro lle d fo r se ve rity, de c re a se d mo rta lity (OR 0.3, p=0.03)

E c ke rt MJ e t a l. T XA a dministra tio n to pe dia tric tra uma pa tie nts in a c o mb a t se tting (PE D- T RAX).J T ra uma Ac ute Ca re Surg 2014;77:852-858.

https:/ / www.rc e m.a c .uk/ d o c s/

Take Home Points

F AST ha sn’ t b e e n ve ry he lpful so fa r in pe dia tric tra uma . But we just mig ht ne e d to le a rn to d o it b e tte r in kid s.

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T XA

Pe rmissive hypo te nsio n in pe dia tric tra uma is pro b a b ly a b a d ide a . But g iving b lo o d e a rly is pro b a b ly a g o o d ide a .

T XA

T XA is like ly to he lp a nd unlike ly to ha rm whe n g ive n e a rly to the se ve re ly injure d pe dia tric tra uma pa tie nt.