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DR NEETHU SUJALA.N -MANAGEMENT OF MAJOR CRUSH INJURIES IN ED

APPROACH & MANAGEMENT OF CRUS INJURIES IN ED<br>

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DR NEETHU SUJALA.N -MANAGEMENT OF MAJOR CRUSH INJURIES IN ED

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  1. MANAGEMENT OF MAJOR CRUSH INJURIES IN ED--DR.NEETHU SUJALA .NCONSULTANT ER PHYSICIAN, SEVEN HILLS HOSPITAL

  2. DEFINITION • CRUSH INJURY—IT’S THE RESULT OF PHYSICAL TRAUMA FROM PROLONGED COMPRESSION OF TORSO,LIMBS OR OTHER PARTS OF BODY. • THE RESULTANT INJURY TO THE SOFT TISSUES,MUSCLES,NERVES CAN BE DUE TO PRIMARY DIRECT EFFECT OF TRAUMA/ISCHEMIA RELATED TO COMPRESSION. • CRUSH INJURY RESULTS IN SWELLING IN THE AFFECTED AREA WITH MUSCLE NECROSIS &NEUROLOGIC DYSFUNCTION.

  3. CRUSH SYNDROME • DEFINED AS THE SYSTEMIC MANIFESTATIONS RESULTING FROM CRUSH INJURY ,RESULTING IN ORGAN DYSFUNCTION eg. AKI, MODS or Death. • The manifestations of crush syndrome –systemic consequences of muscle injury specifically rhabdomyolysis which commonly results in AKI.

  4. SUPPORT A,B,C

  5. CLINICAL MANIFESTATIONS • HYPOVOLEMIA • EXTREMITY CRUSH INJURY • ORGAN INJURY • SEQUELAE OF CRUSH INJURY • AKI • ARDS

  6. RECOGNITION & MANAGEMNT OF HAEMORRHAGE

  7. MANAGEMENT • PLACE TWO WIDE BORE CANNULAS[16-G] m/c: AT ANTECUBITAL FOSSA OF EACH ARM • SEND LABS &BLOOD GROUPING,CROSS-MATCHING • LIFE THREATENING HAEMORRHAGE – • CONTROLLED BY MANUAL PRESSURE, • PROXIMAL COMPRESSION WITH TOURNIQUET / MANUAL BP CUFF • ELEVATION OF THE LIMB ALWAYS AVOID CLAMPING DONOT PUT HAEMOSTATS/FORECEPS

  8. RESUSCITATION- • INITIAL IV CRYSTALLOIDS BOLUS OF 20ML/KG ISOTONIC SALINE • AKI(RHABDOMYOLYSIS)- IV REHYDRATION crystalloids 2.5ml/kg/hrwith a Goal of maintaining urine output of 2ml/kg/hr • EARLY ANTIBIOTIC COVERAGE • BLOOD TRANSFUSIONS [TARGET 1:1:1 /PLASMA:PLATELETS:RED CELLS] • TRANEXEMIC ACID [1GM WITHIN 3 HOURS OF INJURY F/BY INFUSION OF 1GM OVER 8HOURS ] • MANAGEMENT OF COAGULOPATHY • MAINTAIN MAP ABOVE 65mmHg • PERFORM E-FAST • SUPPORT AFFECTED LIMBS WITH SPINTS • TRAUMA TEAM.

  9. THERAPEUTIC DECISIONS BASED ON RESPONSE TO INITIAL FLUID RESUSCITATION!!! *ITS IMPORTANT TO DISTINGUISH B/W ‘HAEMODYNAMICALLY STABLE ‘ VS ‘HAEMODYNAMICALLY NORMAL. H.STABLE Pt.-MAY HAVE PERSISTENT TACHYCARDIA,TACHYPNEA,OLIGUIRIA [still in shock] H.NORMAL Pt.—EXHIBITS NO SIGNS OF INADEQUATE PERFUSION. PATTERN OF RESPONSE • RAPID RESPONDERS • TRANSIENT RESPONDER • NON RESPONDER

  10. RAPID RESPONDERS • GOOD RESPONSE WITH INITIAL FLUID BOLUS • REMAIN HAEMODYNAMICALLY NORMAL AFTER THE BOLUS • HENCE FLUIDS SLOWED TO MAINTAINENCE RATES • USUALLY LOST <20% BLOOD VOLUME • NO FURTHER FLUID BOLUS/IMMEDIATE BLOOD TRANSFUSION NEEDED • SURGICAL CONSULTATION & EVALUATION –NECESSARY DURING INITIAL ASSESSMENT & TREATMENT AS OPERATIVE INTERVENTION MAY BE STILL NECESSARY.

  11. TRANSIENT RESPONDER • RESPOND TO THE INITIAL BOLUS • HOWEVER,BEGIN TO SHOW DETERIORATION OF PERFUSION • INDICATING ON-GOING BLOOD LOSS /INADEQUATE RESUSCITATION. • LOST :20-40% BLOOD VOLUME • BLOOD &BLOOD PRODUCTS TRANSFUSION IS INDICATED CALL TRAUMA TEAM .

  12. NON-RESPONDERS • FAILURE TO RESPOND TO CRYSTALLOID & BLOOD ADMINISTRATION IN ED DICTATES THE NEED FOR IMMEDIATE ,DEFINITIVE INTERVENTION eg. surgery or angioembolization] to control the hemorrhage . TRANSIENT RESPONDER/NON RESPONDER WITH CLASS 3 OR 4 HAEMORRHAGE –NEEDS IMMEDIATE BLOOD TRANSFUSION. Require SURGICAL INTERVENTION IMMEDIATELY.

  13. MAIN PURPOSE OF BLOOD TRANSFUSION: • TO RESTORE O2 CARRYING CAPACITY OF THE INTRAVASCULAR VOLUME • PREFERABLY-FULLY CROSS MATCHED BLOOD . • IN NON AVAILABILTY OF TYPE SPECIFIC BLOOD GROUP –TYPE ‘O’ PACKED CELLS ARE INDICATED • IN WOMEN OF CHILD BEARING AGE—RH NEGATIVECELLS PREFERRED TO AVOID SENSITIZATION/COMPLICATION IN FUTURE.

  14. MASSIVE TRANSFUSION • DEFINED AS >10UNITS OF PRBC WITHIN FIRST 24 HOURS OF ADMISSION . • EARLY ADMINISTRATION OF PRBC,PLASMA,PLATELETS,AGGRESSIVE CRYSTALLOID ADMINISTRATION –IMPROVES SURVIVAL RATES. • THIS APPROACH TERMED AS – • BALANCED ,HEMOSTATIC OR DAMAGE CONTROL RESUSCITATION. • MOST PATIENTS RECEIVING BLOOD TRANSFUSIONS DONOT REQUIRE CALCIUM SUPPLEMENTS

  15. COAGULOPATHY • PROTHROMBIN TIME • PARTIAL THROMBOPLASTIN TIME Valuable Baseline studies to obtain • PLATELET COUNT in first hour • OBTAIN PAST HISTORY : • COAGULATION DISORDER • MEDICATIONS THAT ALTER COAGULATION • H/O.MAJOR BRAIN INJURIES

  16. WHAT IS THE PATIENT’S RESPONSE? • IMPROVEMENTS IN CVP STATUS ,SKIN CIRCULATION ,URINE OUTPUT –evidence for enhanced perfusion. • URINE OUTPUT—SENSITIVE INDICATOR OF RENAL PERFUSION • TARGET—0.5ML/KG/HR IN ADULTS • 1ML/KG/HR IN PADEIATRIC PATIENTS • CHILDREN <1YR OF AGE– 2ML/KG/HR • ACID BASE BALANCE– • METABOLIC ACIDOSIS –RESULTS FROM INADEQUATE TISSUE PERFUSION & PRODUCTION OF LACTIC ACID. • PERSISTENT ACIDOSIS??,--THEN ON GOING HAMORHAGE+ • BASE DEFICIT ,LACTATE –DETERMINES THE PRESENCE & SEVERITY OF SHOCK. • SODA BICARB –NOT USEFUL IN TREATING MET.ACIDOSIS SECONDARY TO HYPOVOLEMIC SHOCK.

  17. THANKYOU!!!

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