DESCRIBE IN DETAIL THE TERRIBLE TRIAD OF DEATH ?
A 10 DEFINITION
1 ALSO KN AS TRAUMA TRIAD OF DEATH
2 The trauma triad of death is a medical term describing the combination of hypothermia, acidosis ( as an arterial pH < 7.35 ) and coagulopathy.
3 This combination is commonly seen in patients who have sustained severe traumatic injuries and results in a significant rise in the mortality rate.
4 Commonly when someone presents with these signs damage control surgery is employed to reverse the effects.
5 The three conditions share a complex relationship; each factor can compound the others, resulting in high mortality if this positive feedback loop continues uninterrupted.
1 Severe haemorrhage in trauma diminishes oxygen delivery, and may lead to hypothermia.
2 This in turn can halt the coagulation cascade, preventing blood from clotting.
3 In the absence of blood-bound oxygen and nutrients (hypoperfusion), the body's cells burn glucose anaerobically for energy, causing the release of lactic acid, ketone bodies, and other acidic compounds into the blood stream, which lower the blood's pH, leading to metabolic acidosis.
4 Such an increase in acidity damages the tissues and organs of the body and can reduce myocardial performance, further reducing the oxygen delivery.
MOST COMMON ASSOCIATED CONDITION ASSOCIATED WITH HIGH MORTALITY
- BLUNT ABDOMINAL TRAUMA
FACTORS RESPONSIBLE FOR HYPOTHERMIA
1 CONCURRENT ALCOHOL INTOXICATION
2 RAPID RESUCITATION OF FLUIDS
MAJOR CONSEQUENCE OF HYPOTHERMIA
1 DECREASED CARDIAC OUTPUT AND MYOCARDIAL ISCHEMIA
2 DECREASED CARDIOVASCULAR RESPONSES TO CATECHOLAMINES
3 IMPAIRED TISSUE OXYGEN DELIVERY
4 ARRHYTHMIAS - A FIB AND V FIB
5 DECREASED FUNCTION OF COAGULATION FACTORS
6 DECREASED NUMBER AND FUNCTION OF WHITE BLOOD CELLS
7 INCREASED RISK OF WOUND INFECTION , SEPSIS AND PNEUMONIA
1 The triad begins and ends with bleeding, so find the bleeding and stop it - Hold pressure, use combat gauze, apply a tourniquet, bind the pelvis, etc.
2 Do not stop your search for bleeding with the first source you find, as others may exist.
3 Always assume your patient’s temperature is dropping right before your eyes, because it is, and much faster than you’d expect.
4 “Strip ‘em and flip ‘em,” but not with reckless abandon.
5 Make every effort to expose only those body parts you’re examining in the moment and keep the remainder of the patient covered.
6 Patients can and will become hypothermic in conditions you consider warm.
7 Prioritize limiting a patient’s exposure to the environment, especially during prolonged extrications.
8 Place a warm blanket between the newly extricated patient and your cold, hard backboard.
9 Turn up the heat in your ambulance. If you aren’t sweating, it’s certainly not warm enough. (Ideally, 27 degrees C.)
10 Promptly remove wet or bloody clothes and replace with a warm blanket.
11 Shivering wastes valuable cellular energy and oxygen in an attempt to stay warm while producing more lactate, contributing to acidosis.
12 We don’t bleed normal saline, so limit crystalloid infusion as much as possible. It contributes to the patient’s acidosis and dilutes the remaining clotting factors in your patient’s blood.
13 IV fluids may improve a number, but may actually hurt your patient in the long run.
Except in those patients with a traumatic brain injury, utilize a permissive hypotension resuscitation strategy.
14 Our goal should be to maintain tissue perfusion typically defined as the presence of a radial pulse or normal mental status.
15 We should avoid overly aggressive fluid administration to normalize blood pressure, which can “pop the clot” and worsen hemorrhage.
Whenever possible, administer only warmed fluids. (Ideally 40 degrees C.)
16 Measure prehospital lactate levels when available to more accurately detect cryptic shock in trauma patients with normal vital signs.
17 End-tidal carbon dioxide may also be a useful marker.
18 Monitor and maximize oxygenation.
19 Treat causes of hypoventilation to prevent a respiratory acidosis.
20 Identify high-risk patients with a baseline coagulopathy due to medications or preexisting medical conditions - Administer tranexamic acid (TXA)—an antifibrinolytic that prevents clot breakdown and thus decrea