Management of Trauma in ICU

8/3/2019 Management of Trauma in ICU

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Severe trauma

Management of Trauma in ICU

Dr Prakash ShastriMD, FRCA

Sir Gangaram HospitalNew Delhi

Trauma management

Primary survey

Secondary survey

Primary survey

Secondary survey

Treatment

Investigations

Treatment

Investigations


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Motor vehicle accident

25 year old driver

Frontal impact

40 kph

Wearing seat belt

Mechanism ofMechanism ofMechanism ofMechanism ofinjuryinjuryinjuryinjury

Related injuriesRelated injuriesRelated injuriesRelated injuries

Frontal impactFrontal impactFrontal impactFrontal impact Cervical spine fracture, flail chest,Cervical spine fracture, flail chest,Cervical spine fracture, flail chest,Cervical spine fracture, flail chest,myocardial contusion, pneumothorax,myocardial contusion, pneumothorax,myocardial contusion, pneumothorax,myocardial contusion, pneumothorax,transection of aorta, rupturedtransection of aorta, rupturedtransection of aorta, rupturedtransection of aorta, rupturedliver/spleen, fracture/dislocation of hipliver/spleen, fracture/dislocation of hipliver/spleen, fracture/dislocation of hipliver/spleen, fracture/dislocation of hipand/or kneeand/or kneeand/or kneeand/or knee

Side impact Cervical spine fracture, lateral flail chest,pneumothorax, ruptured spleen/liver(depending on side of impact), fractureof pelvis/acetabulum

Rear impact Cervical spine injury

Motor vehicle-pedestrian

Head injury, thoracic and abdominalinjuries, fracture of lower extremities


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AirwayMist

Bag inflating/deflating

Airway

Mist

Palpable gasmovement


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Breathing

Usingaccessorymuscles

Chestmovement

Breathing

Respiratory rate35 m n

Unrecordable SpO2 Decreased breath

sounds on left

? Hyper-resonance

on left

Tracheal deviation toright


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Circulation

BP 80/50 HR120/min

Neck veinsdistended

Cold peripheries

Slow capillary refill

Shock

Consider

Tension pneumothorax

Cardiac tamponade

Myocardial contusion

Myocardial infarction


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Tension pneumothorax

Clinical features

Respiratory distress

HR, shock

Tracheal deviation

Unilateral absence of breath sounds and hyper-resonance

Distended neck veins

absent if there is concomitant hypovolaemia

cardiac tamponade

Needle thoracostomy

2nd ICS, MCL

Gush of airconfirmsdiagnosis


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Intravenous access

Chest drain

Circulation improves

BP 110/60

Pulse oximeter 95%

Tachypnoeic

Chest movement symmetrical


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Disability

Glasgow Coma

E2, V2, M4

Pupils

3 mm

Equal

Decision:

Intubate andventilate for airwayprotection

Cervical spine injury

Cannot be excluded on clinical grounds in

Distracting injuries

Decreased consciousness

Optimal method of intubation Controversial

Dependent on skills of operator


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Manual in-line stabilizationStand in front of the patient and to one side

Hold mandible and occiput with both hands

Maintain neck alignment without traction orcounter-traction

Intubation

Rapid sequence induction

Cricoid pressure


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Intubation

Failed intubation

Anaesthetist arrives

Decides to attempt direct laryngoscopy andintubation again after bag-mask ventilation

Intubation

Trauma patients are more difficult ton u a e

Do not intubate unless

you are skilled in intubation

dire emergency


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Hypotension BP 85/40, HR 120/min

of 2L colloid andblood

300 ml drained fromchest drain


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Circulation

ys o c mm g > > < 100 >100 >120 >140

RR (bpm) 16 16-20 21-26 >26

Mental status Anxious Agitated Confused Lethargic

Blood loss (L) 2

Hypotension

oobviousexternalbleeding


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Hypotension

ProgressiveProgressiveProgressiveProgressiveabdominalabdominalabdominalabdominaldistensiondistensiondistensiondistension

-ve FAST

BP 80/40 despite continued fluidresuscitation

Investigations

CT abdomen

Contraindicated in haemodynamicallyunstable patients

Diagnostic peritoneal lavage

Laparotomy


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Indications

aemo ynam c ns a y w unre a e c n cafindings (eg due to head injury, intoxication orparaplegia)

Abdominal examination is equivocal (eg lower rib,lumbar spine or pelvic fractures causing abdominaltenderness and tensing)

Repeated abdominal examination impracticalbecause of anticipated lengthy x-ray studies or GA for

extra- abdominal injuries


Contraindications

so u e: ex s ng n ca on or aparo omy

Relative:

Pregnancy

Significant obesity

Previous abdominal surgery

In these situations (or with pelvic fractures) supra-umbilical


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Hypotension

-ve FAST

esp e

continued fluidresuscitationProgressiveProgressiveProgressiveProgressiveabdominalabdominalabdominalabdominaldistensiondistensiondistensiondistension

Post-op intensive care

History

ec an sm o rauma

Identified injuries

Injuries that have been excluded

Operative findings

Supportive and definitive treatment

Laboratory results

Past medical history, drug allergies etc


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Secondary survey

Fill in the gaps

Look for problems that have becomeapparent with time

Secondary survey

Scalp

yes

Maxillofacial

Spine

Neck

Perineum Cardiovascular

Chest

Abdomen & pelvis

Limbs

Illustration Kathy Mak, 2004


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Investigations

Routine bloods

Radiology

CT brain

Cervical spine lateral & AP, cervical CT

Pelvis XR

ECG

Management

Continued resuscitation

Seek for and exclude other injuries

Correct coagulopathy, acidosis,hypothermia

Treat complications

rgan a ure Distributive shock


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Present Approach

Tolerance of moderate hypotension

,hypothermia

Temporisation / prevention of worsening ofacidosis

Immediate correction of cogaulopathy


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Permissive hypotension

Minimisin fluid and blood roducts deliver inthe prehospital setting

Who have a palpable pulse

Normal mental status

Hypothermia T


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Hypothermia

Heat loss prevention kits

Use of rewarmed fluids / blood roducts

In line warmers

Body cavity lavage

Continuous AV rewarming

CPB

Acidosis - Effects

Decreased clot formation

Platelet dysfunction, decreased plateletcount

Decreased fibrinogen concentration

Decreased thrombin generation

Decreased rate of Factor Xa formation


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Coagulopathy

Perhaps the most treatable

Linked to the other factors

Fresh Whole Blood

Give the patient back the fresh whole blood that helost

Restores myocardial function

Best 24 h hypotensive resuscitative fluid

Decreased blood loss and transfusion requirements

Survival benefit?

Circumvents the problems of Storage lesion


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Blood Product Ratio

Mimicking the delivery of fresh whole blood

p ma ra os o o p asma, p a e e sand cryoprecipitate yet to be elucidated

Survival benefit when FFP:PRBC ratiosapproach 1:1

Newer concepts

Freeze dried plasma products

Purified protein concentrates

Recombinant Factor VIIa

Appropriate timing

e ec on o pa en s

Addition of blood components

Correction of acidosis and hypothremia

Adverse effects


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Prospective Identification of patients whorequire resuscitation

Multi le roximal am utations

Truncal haemorrhage

Adbominal evisceration

Penetrating mechanism

Prospective Identification of patients whorequire resuscitation

INR>1.5

SBP


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Employment of damage control resuscitation

Summary

Begins as soon as the patient is identifiedAs being at risk of death from haemorrhage

The patient will require rapid transfer

For damage control surgery and early admof increased Amount of FFPand packed RedCells than traditionally thought


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Validated End Points of ResuscitationSuch as Lactate and/or Base Deficit

Use of Thrombo Elastographymay decrease un necessary transfusionOf blood and blood products

Thank You

Management of Trauma in ICU

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