GenSurg.nz

Critical care of a trauma patient

Section: Trauma Curriculum: Curriculum, page 75

Phases of ICU care

  • Resuscitative Care = 1st 24 hours
    • Goal - Maintain adequate tissue oxygenation & dealing with life or limb issues
    • Done by haemostatic resuscitation
    • Occult hypoperfusion
      • Inadequate organ perfusion despite normal BP and UO after major trauma
      • Leads to
        • More infections | Longer LOS | MODS | mortality
    • Permissive hypotension or Hypotensive resuscitation
      • Target SBP 90 until surgical bleeding is controlled
      • To avoid dislodging clots and worsening bleeding with higher BP
      • To limit coagulopathy, acidosis and hypothermia
  • Early Life Support Phase - 24-72 hours post injury
    • Dealing with head and lungs
    • Line/emergency device placement optimisation
    • Further investigations - Scans/ X-rays
  • Prolonged Life Support - > 72 hours
    • Support organs
    • Treat infection
    • Nutrition
    • Prevent complications
    • Infection risks
      • Lung
        • Pneumonia | Abscess | Empyema
      • SSI
        • Superficial (wound) | Deep (intra-abdo)
      • Septic Screen Sites
        • Line associated | Urine | Blood
      • Other
        • Acalculous Cholecystitis | Sinusitis | Meningitis

Extubation Criteria

  • S - Secretions are minimal
  • O - Oxygenation is good
  • A - Alert
  • A - Airway is not injured or compromised
  • P - Pressures or parameters - TV, VC etc

Extracorporeal Membrane Oxygenation (ECMO)

  • Definition
    • Allows gas exchange to occur outside of the body to treat respiratory or cardiorespiratory issues
  • Types
    • VV - for respiratory issues only
      • Venous blood out → Gas exchange → Oxygenated blood back to veins
    • VA - for cardioresp conditions
      • Venous blood out → Gas exchange → Oxygenated blood back to arteries
      • Bypass lungs completely
  • Risks
    • Clots
    • Bleeding

Coagulopathy

  • Worsened by:
    • Haemodilution
      • Dilutional thrombocytopenia is the most common issue
    • Consumption
      • Of clotting factors
    • Hypothermia
      • Causes platelet dysfunction
      • Causes reduction in enzyme activity for cascade
    • Acidosis
      • Interfere with clotting mechanism

Hypothermia

  • Protective mechanism which is cerebro-protective
    • Reduced metabolic rate → Reduced oxygen requirement
  • Primary Hypothermia
    • Common after immersion
    • Re-warm with monitoring
    • Resistant to electrical and pharmacological cardioversion
    • Don’t give up when patient is still hypothermic
    • Unsure if cerebro-protective state or dead
  • Secondary Hypothermia
    • Metabolic derangements from trauma
    • Rapid re-warming essential → Aggressive
    • Simultaneously control haemorrhage, secure AW, warmed blood products
    • External mx (remove, blankets, lights)
      • Remove wet/cold clothing
      • Dry the patient
      • Blankets - electrical or warm air
      • Radiant heat - heating lights
      • (Not Space Blankets - no intrinsic body heat to reflect)
    • Internal mx (IVF, gases, lavage, ECMO)
      • Heated and humidified respiratory gases 42 deg
      • Warmed IVF 37 deg
      • Gastric lavage with warmed fluids - saline at 42 deg
      • Continuous bladder lavage water 42 deg
      • Peritoneal lavage - K free dialysate at 42 deg
      • Intrapleural lavage
      • ECMO rewarming

Systemic inflammatory response syndrome

Criteria Definition

  • 2 or more of:
    • HR > 90
    • Temp < 36 or > 38
    • RR > 20 and PaCO2 < 32mmHg
    • WBC < 4 or > 12 or > 10% bands
  • Practical Explanation
    • Severe and destructive tissue injury activates the Inflammatory cascade
    • Become exaggerated or inappropriate
    • Can be beneficial or more frequently, harmful

Pathogenesis

  • Systemic Inflammatory Response Syndrome – Dysregulated host inflammatory response to an injury or infection
  • Imbalance between pro-inflammatory and anti-inflammatory cascade
  • Stage 1: Activation
    • Initial Insult
      • Infection
      • Trauma
      • Pancreatitis
    • Activation of Innate immune cells
      • PRR active by DAMPs or PAMPs
    • Release of proinflammatory mediators
      • Pro-inflammatory cytokines: TNF-alpha, Interferon-Gamma, IL-1, IL-6, IL-8
      • Activation of inflammatory cascade
      • Released from tissue macrophages, monocytes and platelets
  • Stage 2: Systemic Response
    • Vascular and cellular phase
      • Increased vascular permeability
      • Spill over of inflammatory cytokines into systemic circulation that recruits more inflammatory cells
      • Recruitment of PMN, lymphocytes, macrophages, and platelets
    • Systemic effects
      • IL-1 and TNF-Alpha causes fever
      • Cytokines activate stress hormones, e.g. noradrenaline, adrenaline and ADH
      • Activation of renin-angiotensin system
      • Activation Coagulation Cascade and Complement cascade
        • Completement 3a and 5a cause vasodilatation and hypotension
      • Prostaglandins and leukotrienes released – endothelial damage and increased vascular permeability
      • Further fluid loss, hypotension, and multi-organ dysfunction in lungs and kidneys
  • Stage 3:
    • CARS - compensatory anti-inflammatory response
    • Intended to stop inflammatory reaction
    • IL-4, IL-10 and TGF-Beta inhibit production of further inflammatory cytokines
    • If imbalance, patients suffer full effects of inflammatory response

Supportive care

  • AKI
    • Usually caused by under resuscitation or MODS
    • Identify and manage the causes
    • Hypovolaemia
    • Rhabdo
    • ACS
    • Obstructive uropathy
    • Avoid nephrotoxic dyes
  • Nutrition
    • Trauma pts = Hypermetabolic and have increased nutritional needs
    • Immunological response to trauma
    • Accelerated protein synthesis for wound healing
    • Early enteral feeding reduces subsequent infective complications
  • Prophylaxis in ICU
    • Stress Ulceration
      • Who is high risk
        • Known PUD
        • Requiring mechanical ventilation
        • Coagulopathy
        • Steroids
        • Burns
      • PPI IV
      • Cytoprotective agents - Sucralfate
        • MOA - Not well known
        • Topical agent that creates a physical barrier between luminal contents and mucosa
        • Prevents mucous breakdown
        • SFX - Constipation
        • Bonus - its use reduces VAP
      • Adequate resuscitation and early enteral feeding (when appropriate)
      • Usually wait a few days before enteral feeding so can use Sucralfate and PPI in that stage
    • VTE prophylaxis
    • Vaccinations
      • Tetanus if not had within 5 years or not sure
      • Post-splenectomy against Haemophilus B, Neisseria and Pneumococcus
  • Analgesia
    • Signs of poor pain control
      • Increased oxygen consumption
      • Increased RR
      • Stress
      • Sleep deprivation
      • Impaired lung mechanics
      • Pulmonary complications

FAST-HUG-BIDS ICU Surgical Patient Assessment

  • Feeding - NPO/PO/enteral/TPN
  • Analgesia
  • Sensorium - GCS
  • Thromboprophylaxis/Temperature/Tubes
  • Head-up position/Haemodynamics
  • Ulcer prophylaxis/UO
  • Glycaemic control
  • Bowel movement - ileus/gastroparesis/distension
  • Indwelling lines/imbalances
  • Drug de-escalation

Other

Graph View

Backlinks