Practical ABCDE management of severe trauma patients (Proceedings)
The object of this review is to convey new scientific information and resultant practical techniques applicable to the care of the severely injured patient. One near death, severely injured patient is then briefly presented to exemplify A – airway, B-breathing C- cardiovascilar, D – disability, E – everything else techniques that contributed to her recovery.
Trauma can affect many body systems and a priority of need dictates the appropriate response. This priority concept is not new and is still based on the ABC's. However new experience has provided an increased emphasis on the importance of a clear airway, support of ventilation, early arrest or at least the augmentation of hemorrhage, and metabolic supportive techniques that are either designed to provide the oxygen and substrates that are necessary, or the augmentation of the bodies need of them. An example of this is use of hypothermia and induced coma or "anesthesia" that places the patient in a state of "suspended hibernation" for a period of time. This time allows the shocked cells to recover enough that they can resume a gradual return to normal function. At this time we are using mild hypothermia (93-98 degrees) in resuscitation when surgery is not required and moderate hypothermia (89-92 degrees) during resuscitation when surgery is required very commonly during the initial phases of trauma care. Then after restitution of the patient's oxygen debit and hypovolemia active rewarming is done slowly over 8 to 24 hours.
The following techniques have been developed by the author, or adapted by the author from techniques that are now used in the care of humans, which have been found to be critical importance in the care of seriously injured small animal patients:1. A. Rapid and aggressive use of the tracheostomy including awake tracheostomy, tracheostomy use in the severely pulmonary traumatized patient that allows tracheal toiletry and direct support of ventilation;
2. AB. Jet-blow by oxygen stream ventilation, where, on arrival the spontaneously breathing trauma patient is provided a forceful stream of 100% oxygen delivered directly to their nose and mouth area. The stream is generated by attaching a 14 g IV 1-2 inch catheter to a commercial oxygen tubing line or to an IV solution administration set that is connected to a flow-meter regulator or to one arm of a Y connector that is placed in-line with the oxygen supply line of an anesthetic machine prior to it entering into the circle-system part of the machine. The jet stream delivered to an animal that is open mouth breathing will assist that animal's ability to take in the fresh gas on each inhalation effort. The jet stream will also provide a small level of positive airway pressure during exhalation and assist in increasing functional residual capacity. This will decrease the patient's level of work of breathing and be particularly beneficial in those patients with pulmonary contusion, intrapulmonic hemorrhage and edema. It is used during the initial phases of care when IV access is being obtained.
3. AB. Noninvasive ventilation by use of a bag-valve-mask and the attachment of a PEEP valve on the exhalation arm of the bag-valve. This provides the trauma team the ability to administer Bi-PAP ventilation on almost on a moment's notice whenever any patient arrives that is having difficulty with breathing. The Bi-PAP ventilation involves the squeezing of the bag with each breath the patient attempts to take thus giving an assisted ventilation which lowers the patient's work of breathing. When the patient exhales the exhaled breath is somewhat impeded by the peep valve which causes in retainment of some of the exhaled breath which increases functional residual capacity. Animals that arrive conscious enough to fight a mask are given an IM or IV injection of ketamine 1-2 mg/kg, butorphenol 0.1-0.2 mg/kg, acepromazine 0.01 – 0.02 mg/kg. It is then recommended to perform immediate ultrasound focused examination on the thoracic cavity to determine whether pneumothorax is present. If present then the thoracentesis or a chest tube may be needed as this noninvasive support ventilation may cause additional increases in pleural air. The mask can also be taped to the patient's head or placed into a cloth muzzle to continue the Non-Invasive Ventilation with a mechanical ventilator.
4. AB. The automatic "routine use" of mechanical ventilation for support of pulmonary function during the first 12 to 24 hours post admission in severely injured patients. This is in conjunction with the use of continuous rate infusion pentobarbital to induce a light barbiturate coma and allow the patient to tolerate can use mechanical pressure support ventilation with a lease of positive end expiratory pressure at the conclusion of the exhalation phase of each breath as a "protective lung strategy"