ICU-Surviving Trauma Guidelines

Brain trauma foundation

Levels of evidence

Class 1: Things I believeClass 1 : Things I believe despite the dataClass 1: Randomised controlled clinical trials that agree

with what I believeClass 2: Expert opinion that agrees with meClass 3: Other data that agrees with meClass 4: Randomised controlled clinical trials that don't

agree with what I believeClass 5: What you believe and I do not

Prehospital

• M -28 yo female, high speed MVC• I -abdominal tenderness, seatbelt

bruise, difficulty breathing and talking, pregnant 32/40

• S -HR 166 BP 75/- RR 38 GCS 14• T -250ml Hartmanns

ED Primary Survey• A -One word replies, c-collar on

• B -RR 40 ?decreased BS left chest, SaO290%

• C -HR 124 BP 105/65, wedge under right side• D -GCS 14

• FAST - free fluid, seatbelt bruise, tender abdomen• Left ankle # • Off spine board, spinal exam and PR• CXR done What Now?

Plan for OT

• Pale, gasping• Intubated T+13 min

• T+14 min: difficulty ventilating• Decreased BS L and R chest

• Bilateral chest tubes T+ 20 min

OT (+30min)

• Laparotomy• Ruptured uterus: intra-abdominal foetus-deceased• Hysterectomy• Ruptured left hemidiaphragm -sutured• Bowel NAD• Retroperitoneal structures NAD• Liver and spleen NAD• Contused and collapsed left lower lobe• No haemopericardium

Surgery terminated at 1 hour

• Damage Control• Packs to pelvis and to left upper quadrant• Temporary abdominal closure• 7 PRBCs, 4 FFP, 1 pooled platelets

ICU • HR120, BP 100/76

• pH 6.95 PaCO2 62 PaO2 203, HCO3- 16, BE -10, lactate 5.8

• Temp 35ºC• HB 90, Plts 98, • PT 15.7 (10.5-13.5), APTT 39(25-37), INR 1.4, fibrinogen 1.90

(2-4.3)

What Now?

Role for ICU

• Optimisation of systems: Haemodynamics, oxygenation/ventilation, renal function, nutrition

• Correct hypothermia, coagulopathy and acidosis (the TRIAD)

• Monitoring –BP, IAP, ScvO2, UO

Rules of Intensive Care

• Assume nothing• Trust no one• Give oxygen (enough, not too much)

• History (PMH and medications)• Examination• ALL investigations and imaging

Resuscitation Endpoints

EAST: Level 1• Standard hemodynamic parameters do not adequately

quantify the degree of physiologic derangement in trauma patients.

• Base deficit, lactate level, should be used to stratify patients with regard to the need for ongoing fluid resuscitation, including PRBCs and other blood products, and the risks of MODS and death. 

• Oxygen delivery parameters: ability of a patient to attain supranormal correlates with an improved chance for survival relative to patients who cannot achieve these parameters. 

Balogh, Z et al. Abdominal Compartment Syndrome: The Cause or Effect of Postinjury Multiple Organ Failure.

Shock 2003;20:483-492

• Patients have a pulmonary artery catheter and gastric tonometer placed and are resuscitated according to a protocol to achieve a specified oxygen delivery index (DO2I) goal for 24 h.

• Interventions: – 1) PRBC transfusions if Hb <10 g/dL, – 2) crystalloid boluses to increase PCWP >=15 mmHg if DO2I <

goal – 3) Starling curve generation with successive 500 mL crystalloid

boluses to optimize CI-PCWP relationship if Hb >=10 g/dL, PCWP >=15 mmHg, and DO2I < goal

– 4) inotrope if CI-PCWP has been optimized and DO2I < goal – 5) vasopressor if mean arterial pressure <65 mmHg

– At the inception of the protocol, DO2I >= 600 mL/min/m2 was the goal of the protocol process. This goal was chosen by review of the published literature and local consensus opinion.

– After 2 years, based on consensus groups concerns over the large volume of crystalloid being administered (13 litres in 24 hours) and publication of the most recent trial by Shoemaker and colleagues which failed to demonstrate improvement in survival in trauma patients with a similar protocol process with a DO2 >= 600 goal, we decreased the DO2I goal in patients to 500 mL/min/m2

What fluid?

How much?

Transfusion Guideline• In patients hemodynamically unstable as defined by:• SBP ≤ 90 mmHg or • SBP is only maintained > 90 mmHg with massive fluids or vasopressor

support • RBC should be administered as determined by "clinical necessity".

• In patients hemodynamically stable as defined by:• No SBP≤ 90 mmHg for 1 hour and • No resuscitation (or use of vasopressor support) (exception: use of low

dose vasopressor support for neurogenic shock) • Hemoglobin < 7g/dL: RBC justified• Hemoglobin 7-9 g/dL: RBC if evidence of hypoperfusion is present • Hemoglobin > 9 g/dL: No RBC transfusions

Ventilation weaning

Patients requiring mechanical ventilation will be ventilated to achieve:

• Decreasing FiO2 (and PEEP) as early as possible.

• Limiting ventilation volumes to no greater than 6+/-2 ml/kg predicted body weight as much as possible

• Limiting plateau pressures to ≤ 30 cm H20 whenever possible• Avoiding the use of muscle relaxants.• Attempting to wean on an ongoing basis.

Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000; 342: 1301-1308.

Time to re-evaluate

• Vital signs• Clinical examination• Blood loss• Urine output• Repeat ABG (lactate and BD), FBC and

coagulation

RAPTORResuscitation with Angiography, Percutaneous Techniques and Operative Repair

Clinical examination is an inaccurate predictor of intra-abdominal pressure. World Journal of Surgery 2002;26:1428-1431.

Intra-abdominal hypertension and abdominal compartment syndrome

• An objective assessment of IAP is required

• IAP can be estimated from the transduced pressure of an indwelling urinary catheter

• A pressure >30 mmHg confirms ACS and requires return to OR for initial or further decompression.

Strategies to correct coagulopathy

• Still bleeding?• Intracerebral bleed?• Guided vs empiric• Repeat tests and modify treatment accordingly

• The patient is going to be prothrombotic in 24 hours!

• Start physical VTE prophylaxis

Role for ICU

• Diagnose all injuries• Prevention of complications• Infection control- remove dirty lines• Make a comprehensive plan

– Factor in previous co-morbidities

• Discussion with patient / family

Traumatic rupture of aortaDiaphragmatic ruptureBowel injuryFractures / ligament damageNerve injury

A patient at risk??

Cervical Spine Injuries Following Trauma

Obtunded patient with a negative CT and gross motor function of all four extremities:

• F/E radiography should not be performed (level 2).• The risk/benefit ratio of obtaining MRI in addition to CT is not clear, and its

use must be individualized in each institution (level 3).

Options are as follows:A. Continue cervical collar immobilization until a clinical examination can be

performed.B. Remove the cervical collar on the basis of CT alone.C. Obtain MRI.

3. If MRI disclosed nothing abnormal, the cervical collar may be safely removed (level 2).

Cervical Spine Injuries Following Trauma

Obtunded patient with a negative CT and gross motor function of all four extremities:

• F/E radiography should not be performed (level 2).• The risk/benefit ratio of obtaining MRI in addition to CT is not clear, and its

use must be individualized in each institution (level 3).

Options are as follows:A. Continue cervical collar immobilization until a clinical examination can be

performed.Remove the cervical collar on the basis of CT alone.C. Obtain MRI.

3. If MRI disclosed nothing abnormal, the cervical collar may be safely removed (level 2).

Prevent further complications

• Mouth care• Feeding• Analgesia• Sedation• Thrombo-prophylaxis• Head of bed elevated• Ulcer prophylaxis• Glucose management

• Damage control strategies• Ventilation weaning (use sedation and pain scoring)• Blood product guidelines• Tertiary survey

Further progress ICU

• Right chest drain 285ml output• Left chest drain output 2800ml ?chyle• Patient not haemodynamically unstable• Diaphragmatic repair was inspected at

definitive closure - intact and sound