ICU Trauma Care

ICU and post-injury care

Divided into first 24 hours, 1-7 days and then 8+ days

First 24 hours (stabilization and secondary survey)

Resuscitation (First 24 hours)

Duration and degree of shock is a risk factor for subsequent organ dysfunction and infection.

Goals: fluid resuscitation and maintaining oxygenation; Identify occult injuries through tertiary survey.

Goal-directed therapy

· U/O – 30ml/Kg/hr

· Hb 12-15

· HR 100

· SBP 120

· CVP 12-15

· DO2: 500ml O2/min/m2

· CI: 4l/min/m2

· Central venous O2 saturation >70%

· The more invasive monitoring and goal-directed therapy has not been shown to improve outcome over measurement and correction to parameters that can be measured with a IDC, arterial line and Central Venous catheter. However patients who achieve supra-normal goals have a better outcome.

Hypothermia

· Thermoregulation is compromised in trauma and heat is continually lost through convection, conduction, radiation and evaporation

· Minimizing heat loss is much easier than correcting hypothermia: warmed room, foil blanket, warned/humidified ventilator circuit, warmed fluids, warming blanket.

· Treatment for hypothermia can relay on passive warming (heat generated by oxygen consumption through metabolism) or active warming (radiant warmer, body cavity warming, CPBP, continious arteiovenous rewarming.

· Active rewarming is required when temp <34.5

· Extra-corporeal warming is the most effective but radiant heat is an alternative

Coagulopathy

· Massive transfusion/dilution from crystalloid, hypothermia , acidosis

· Consumption of clotting factors – especially from tissue thromboplastins released from damaged tissues can produce marked reductions in fibrinogen

· Combinations of paltelts, FFP and cyroprecipiate are required.

Start massive Tx protocol based on clinical coagulopathy or transfusion of >6-10 PRC.

One FFP and Platelet unit for every unit PRC once 6u PRC exceeded.

Aim for PT<16s, Platetlts >50000 and fibrinogen >100mg/dl.

· Treatment does not require laboratory confirmation and coagulopathic bleeding mandates empiric treatment

· Recombinant factor VIIa binds to tissue factor at exposed sites and stimulates coagulation – may be useful in patients already treated with platelets, FFP and cryoprecipitate.

TBI

· Any clinical deterioration or rise in ICP warrants repeat CT scan

· Hypotension increase the risk of death and should be avoided

· Post-traumatic seizures should be treated prophylactically with phenytoin

· Maintain normocapnia

Mechanical ventilation

· Acute hypoxia in the first 24 hours is probably different from ARDS.

· High peak pressures may be required at this stage, although the approach will change once the patient has been successfully resuscitated.

Abdominal compartment syndrome

· An intra-abdominal pressure >20mmHg (with or without APP <60mmHg) in association with new organ dysfunction or failure

· Abdominal perfusion pressure = MAP-IAP

· Cause of raised IAP

Intra-abdominal and retroperitoneal haemorrhage

Massive fluid resuscitation with bowel and tissue oedema

Tissue oedema due to sepsis or ischaemia

Paralytic ileus or pseudo-obstruction

· Clinical features: Tense abdomen, increased end-inspiratory pressures, oliguria, reduced CO, increased SVR.

How do you measure bladder pressure?

· I ensure the patient is supine

· I disconnect the bladder from collection bag

· I palce a T piece on the end of the catheter and reconnect one limb to the drainage bag and clamp

· I connect the other end to the electronic pressure transducer

· I instill 50ml saline through the other end of the T piece and zero the system.

· The normal pressure is less than 12mmHg at end of expiration with variations of 5-10mmHg with respiration.

· If the pressure is very high it is probably blocked.

· I flush the catheter

· An alternative is to instill 50ml into bladder and elevate the tubing and measure the height. 1mmHg = 1.3cm water.

            Management principles

· Frequent re-measurement

· Optimizing systemic perfusion and organ function

· Look for reversible factors – stop haemorrhage, treat pseudo-obstrcution

· Decompressive laparotomy –intra-abdominal pressure elevation in absence of physiological derangement is not indication:

· Origuria or persistent shock with raised intra-abdominal pressure despite resuscitation

· A laparotomy with temporaru abdominal closure technique is used

Full length laparotomy is recommended

 

Days 1-7

· Extubate the patient as early as possible – SOAAP

S- Secretions: minimal

O- Oxygenatio good

A – Alert

A – Airway without injury

P – Pressures and parameters satisfactory.

· Consider tracheostomy in patients unlikely to be weanable

· ARDS defined by diffuse bilateral pulmonary infiltrates on CXR, cardiogenic pulmonary oedema excluded, PaO2/FiO2 <200mmHg

· High airways pressures and repeated alveolar collapse (lack of PEEP) contribute to ARDS.

· Moderate PEEP and restricted tidal volume (6ml/Kg) and moderate FiO2 all reduce the extent of lung injury.

Nutrition

· Should be enteral whenever possible.

· Commencing enteral nutrition is possible once shock has resolved. Tolerated within 12 hours of being resuscitated by 80% of patients.

· Calorie requirement can be estimated using the Harris-Benedict equation based on sex, age, weight and height.

· Typical calorie requirement is 30kcal/Kg/day.

· Depending on the severity of injury the basal energy requirement is multiplied by a stress factor usually about 1.3-1.4. eg 35-40 kcal/kg/day

Fluid

Maintenance water is 25 - 35 ml/kg per day

Electrolytes

Electrolyte Amount required (mmol/kg/day)

Sodium 1.5

Potassium 1

Chloride 1.5

Magnesium 0.2

Phosphate 1

Energy and protein

Generic

— Glucose:fat 50:50

— 35-40 kcal/kg/day

·Protein

— 1g/kg/day

Nitrogen requirement

300 mg/kg/day

Essential fatty acids

· 15g each of linoleic and arachidonic acids are required per week.

— (given as Liposyn 500ml via peripheral line once per week)

· Extra fat given to provide extra calories when dextrose not enough,

— but no more than 3g/kg/day.

Trace elements & vitamins

Given as 10ml of multivitamin mixture daily

In depleted or stressed patients;

— Folate 10mg daily for 3 days followed by 5mg per day

— Zinc 10mg daily for the first week

Vitamin B12 given IM 1000 ug/month

·Vitamin K given IM 20 mg/week

Specific TPN composition

· 50% glucose

— Max rate » 15g/hr otherwise XS CO2 and XS fat production

— Min rate » 2g/kg/day to prevent gluconeogenesis

· 30% lipid

· 20% protein

Stress ulceration

· Noscomial pneumonia is increased in patients receiving H2-antagonist

· Sucrasulfate reduces the incidence of gastric ulceration without causing gastric acid neutralization.

Pain relief

Adequate relief of pain. Thoracic epidural results in fewer nosocomial pneumonia and fewer days of ventilator days

DVT/PE

Occur at any time after the first 48 hours.

Spinal cord and lower extremity are particularly high risk

LMWH are more effective than UFH, but the risk of bleeding is greater and therefore should be avoided in intracranial haemorrhage or ongoing extra-cranial haemorrhage.

After first week

 

Nosocomial pneumonia

 

Other infections