Management of Trauma in ICU
Transcript of 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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Diagnostic peritoneal lavage
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
Diagnostic peritoneal lavage
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