1/10/2011

Severe trauma

Management of Trauma in ICU

Dr Prakash Shastri
MD, FRCA

Sir Gangaram Hospital New Delhi

Trauma management
Primary survey Primary survey

Secondary survey

Secondary survey

Investigations

Investigations

Treatment

Treatment

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Motor vehicle accident

25 year old driver Frontal impact 40 kph Wearing seat belt

Mechanism of injury Frontal impact

Related injuries Cervical spine fracture, flail chest, myocardial contusion, pneumothorax, transection of aorta, ruptured liver/spleen, fracture/dislocation of hip and/or knee Cervical spine fracture, lateral flail chest, pneumothorax, ruptured spleen/liver (depending on side of impact), fracture of pelvis/acetabulum Cervical spine injury Head injury, thoracic and abdominal injuries, fracture of lower extremities

Side impact

Rear impact Motor vehiclepedestrian

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Airway
Mist Bag inflating/deflating

Airway
Mist

No stridor Palpable gas movement

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Breathing

Using accessory muscles

Chest movement

Breathing
Respiratory rate 35/min Unrecordable SpO2 Decreased breath sounds on left ? Hyper-resonance on left Tracheal deviation to right

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Circulation
BP 80/50, HR 120/min Neck veins distended Cold peripheries Slow capillary refill

Shock
Usually due to hypovolaemia 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 hyperresonance Distended neck veins
absent if there is concomitant hypovolaemia

cardiac tamponade

Needle thoracostomy
2nd ICS, MCL Gush of air confirms diagnosis

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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 Score
E2, V2, M4

Pupils
3 mm Equal Reactive

Decision:
Intubate and ventilate for airway protection

Cervical spine injury

Cannot be excluded on clinical grounds in patient with multiple trauma
Distracting injuries Decreased consciousness

Optimal method of intubation

Controversial Dependent on skills of operator

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Manual in-line stabilization

Stand in front of the patient and to one side Hold mandible and occiput with both hands

Maintain neck alignment without traction or counter-traction

Intubation
Rapid sequence induction
Cricoid pressure

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Intubation
Failed intubation Anaesthetist arrives
Decides to attempt direct laryngoscopy and intubation again after bag-mask ventilation

Intubation
Trauma patients are more difficult to intubate Do not intubate unless
you are skilled in intubation dire emergency

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Hypotension
BP 85/40, HR 120/min despite transfusion of 2L colloid and blood 300 ml drained from chest drain

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Circulation
Systolic BP (mmHg) HR (bpm) RR (bpm) Mental status Blood loss (L) >110 >100 16 Anxious <0.75 >100 >100 16-20 Agitated 0.75-1.5 <90 >120 21-26 Confused 1.5-2 <90 >140 >26 Lethargic >2

Hypotension
No obvious external bleeding

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Hypotension

Progressive abdominal distension -ve FAST BP 80/40 despite continued fluid resuscitation

Investigations
CT abdomen
Contraindicated in haemodynamically unstable patients

Diagnostic peritoneal lavage Laparotomy

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Diagnostic peritoneal lavage

Indications
Haemodynamic instability with unreliable clinical findings (eg due to head injury, intoxication or paraplegia) Abdominal examination is equivocal (eg lower rib, lumbar spine or pelvic fractures causing abdominal tenderness and tensing) Repeated abdominal examination impractical because of anticipated lengthy x-ray studies or GA for extra- abdominal injuries

Diagnostic peritoneal lavage

Contraindications
Absolute: existing indication for laparotomy Relative:
Pregnancy Significant obesity Previous abdominal surgery In these situations (or with pelvic fractures) supra-umbilical open method should be used

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Hypotension

Progressive abdominal distension

-ve FAST BP 80/40 despite continued fluid resuscitation

Post-op intensive care

History
Mechanism of trauma Identified injuries Injuries that have been excluded Operative findings Supportive and definitive treatment Blood loss & blood/fluid transfused Laboratory results Past medical history, drug allergies etc

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Secondary survey
Fill in the gaps Look for problems that have become apparent with time

Secondary survey
Scalp Eyes 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 CXR

ECG

Management
Continued resuscitation Seek for and exclude other injuries Correct coagulopathy, acidosis, hypothermia Treat complications
Organ failure Distributive shock

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Present Approach
Tolerance of moderate hypotension Recognition, prevention and treatment of hypothermia Temporisation / prevention of worsening of acidosis Immediate correction of cogaulopathy

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Permissive hypotension
Minimising fluid and blood products delivery in the prehospital setting Who have a palpable pulse Normal mental status

Hypothermia
T<32 deg C has been associated with 100% mortality Decreased coagulation factor activity approx. 10% for each degree C decrease Emphasis on external control Limiting removal of clothing Wool / solar blankets In line fluid warmers

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Hypothermia
Heat loss prevention kits Use of prewarmed fluids / blood products In line warmers Body cavity lavage Continuous AV rewarming CPB

Acidosis - Effects
Decreased clot formation Platelet dysfunction, decreased platelet count 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 he
lost 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 Optimal ratios of PRBC to plasma, platelets and cryoprecipitate yet to be elucidated Survival benefit when FFP:PRBC ratios approach 1:1 Newer concepts
Freeze dried plasma products Purified protein concentrates

Recombinant Factor VIIa

Appropriate timing Selection of patients Addition of blood components Correction of acidosis and hypothremia Adverse effects

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Prospective Identification of patients who require resuscitation

Multiple proximal amputations Truncal haemorrhage Adbominal evisceration Penetrating mechanism

Prospective Identification of patients who require resuscitation

Base deficit > 6 INR>1.5 SBP<90 Hb<10 T<35 deg C Weak / absent radial pulse

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Summary
Employment of damage control resuscitation Begins as soon as the patient is identified As being at risk of death from haemorrhage

The patient will require rapid transfer to OT For damage control surgery and early adm of increased Amount of FFP and packed RedCells than traditionally thought

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Validated End Points of Resuscitation Such as Lactate and/or Base Deficit Use of Thrombo Elastography may decrease un necessary transfusion Of blood and blood products

Thank You

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