Stein – What kills you in the first 20 minutes after injury

What Kills You in the First 20 Minutes After Injury (Deborah Stein, MD) *Summary written by Mair Wallis, MD Injury is the leading cause of death for ages 1-44. The mean age of trauma patients, however, is now up to 42 (was previously in late 30s). Fortunately, there is the algorithm that may people are familiar with, utilized by ATLS: A-B-C-D-E: Airway, Breathing, Circulation, Disability and Exposure. That being said, there is a slight shift in the understanding that some types of hemorrhage may kill a patient before loss of airway, and that sometimes prior to addressing airway with intubation, optimizing the patient may be best. This shifts the paradigm to C-A-B; it is only applicable in certain situations and should be done with careful consideration.

Breaking it down by letter

Airway:

Things that can compromise the airway:

• High spinal cord injury
• Oral maxillofacial injury
• Tracheal injury
• Inability to protect airway (Shock, Brain injury, and Intoxication which may be more common, but MUST RULE OUT THE FIRST TWO!)

Breathing:

• Hypoxia
• Hypercarbia
• Pulmonary contusions
• Tension pneumothorax (although it should be noted that it is decreased preload due to increased intrathoracic pressure that ultimately causes hemodynamic collapse, and one could argue this also belongs under “circulation”

Circulation:

• Tamponade Tamponade can be dealt with either by opening the chest or pericardiocentesis. This is another decision requiring careful consideration. For example, in resource limited setting where a surgeon and an OR are not readily available, pericardiocentesis may be the best option for a patient; opening a chest in a more austere environment may be not be beneficial.
• Bleeding
  • Compressible (e.g., extremity)
  • Non-compressible – chest, retroperitoneum, abdomen/pelvis For non-compressible trauma there are two immediate options if the patient is extremely unstable or in traumatic arrest: opening the chest and REBOA (resuscitative endovascular balloon occlusion of the aorta)

Deficit:

• In the first 20 minutes, which patients can you actually affect outcomes in: patients with unilateral mass lesion
• How to tell: Unequal pupils, lateralizing signs, rapid decrease in GCS and Cushing’s reflex which is demonstrative of increased ICP (as the brain tries to maintain cerebral perfusion pressure, blood pressure increases; simultaneous reflex bradycardia then occurs due to response by the baroreceptors)
• In patients with any of these findings, emergent neurosurgical consultation may be warranted

Exposure:

This is an important part of trauma – Key point emphasized here is that while it is important to keep a patient warm given the risk of coagulopathy. However, cooling a patient who is NOT already coagulopathic – like we do in targeted temperature management – should not induce coagulopathy

Notes

REBOA

• Can be placed a Zone 1 where it will occlude at the diaphragmatic hiatus – A limited amount of time exists for REBOA to be up in zone 1 when you consider what is not receiving blood flow during this time (e.g., gut, kidneys, liver); <20 minutes is ideal.
• Zone 3 at the bifurcation of the aorta into the common iliac arteries for pelvic bleeding.

Damage control resuscitation principles:

• Minimize crystalloid
• Balanced 1:1 resuscitation
• Permissive hypotension