SURGICAL CRITICAL CARE REVIEW TRAUMA K. INABA, MD FACS LAC+USC MEDICAL CENTER
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1 SURGICAL CRITICAL CARE REVIEW TRAUMA K. INABA, MD FACS LAC+USC MEDICAL CENTER
2 None DISCLOSURES
3 OBJECTIVES CPMT SYNDROME ABDOMEN EXTREMITY
4 OBJECTIVES CPMT SYNDROME ABDOMEN EXTREMITY
5 Abdominal Compartment Syndrome Described in 19 th century Became increasingly problematic with increasing resuscitation Continues to impact critically ill patients today
6 Abdominal Compartment Syndrome Definitions Clinical presentation Measurement Treatment
7 Abdominal Compartment Syndrome Definitions Clinical presentation Measurement Treatment
8
9 IAH/ACS Definitions IAP: pressure within abdominal cavity (mmhg) Normal is 5 7 mmhg, higher if obese IAH: sustained elevation >12 mmhg Gr I: mmhg Gr 2: mmhg Gr 3: mmhg Gr 4: >25 mmhg
10 IAH/ACS Definitions IAP: pressure within abdominal cavity (mmhg) Normal is 5 7 mmhg, higher if obese IAH: sustained elevation >12 mmhg Gr I: mmhg Gr 2: mmhg Gr 3: mmhg Gr 4: >25 mmhg
11 INCREASED IAP
12 IAH/ACS Definitions ACS: IAP >20 mmhg + Organ Dysfunction Renal failure decreased u/o Cardiac failure hypotension Respiratory failure high peak and plateau P Primary: injury or disease in abdomen Secondary: conditions that do not originate within abdomen Recurrent: redevelops following previous surgical or medical treatment
13 IAH/ACS Definitions ACS: IAP >20 mmhg + Organ Dysfunction Renal failure decreased u/o Cardiac failure hypotension Respiratory failure high peak and plateau P Primary: injury or disease in abdomen Secondary: conditions that do not originate within abdomen Recurrent: redevelops following previous surgical or medical treatment
14 MANY CAUSES Trauma Post Surgery Burns Ascites Resuscitation Ileus Colonic pseudo obstruction Pancreatitis
15 Diagnosis Measuring Pressure Physical exam insensitive Imaging not useful Plain films CT MRI
16 Diagnosis Measuring Pressure Water column or transduction Bladder most common, gastric rare
17 Diagnosis Standard Foley 3-way stopcock 20cc syringe To Water Column
18 Measuring IAP Supine End expiration, relaxed Zero at iliac crest mid axillary line Expressed as mmhg (1 mmhg = 1.36 cmh 2 0
19 Measuring IAP Use <25 ml or 1 ml/kg max of 20 ml water seconds after water instilled Wait for equilibration Repeat as required
20 TREATMENT Minimize crystalloid resuscitation degrees Decompress stomach with NG Sedation / analgesia NMB
21 TREATMENT Burns Percutaneous decompression if intraperitoneal fluid Surgical decompression
22 SUMMARY ACS High index of suspicion in pts with risk factors and distended abdomen IAP>12mmHg= IAH IAP>20mmHg+organ dysfunction= ACS Hypotension, urine output, peak/plateaus Rx = medical +/- drainage +/- laparotomy
23 EXTREMITY COMPARTMENT SYNDROME
24 Volkmann ( ) Described sequelae of untreated compartment syndrome
25
26
27
28 GENERAL Compartment pressure exceeds perfusion External-reduced volume Internal-increased content
29 GENERAL Compartment pressure exceeds perfusion External -reduced volume -cast/dressings -burn
30 GENERAL Compartment pressure exceeds perfusion Internal -increased content -exercise -fracture -crush, hematoma -vascular injury -iatrogenic
31 yr review 10,315 extremities 2.8% fasciotomy rate
32 2011 Leg Forearm Thigh Arm
33 2011 Other MCC SW GSW
34 Combo Arterial Venous 2011
35 2011 Closed #
36 Combo Arterial Venous Closed # % with NO extremity injury
37 DIAGNOSIS UN-EVALUABLE EVALUABLE
38 DIAGNOSIS UN-EVALUABLE EVALUABLE
39 UN-EVALUABLE NO Imaging NO Serologic markers NIRS-not yet Direct Compartment Pressure Measure
40 UN-EVALUABLE NO Imaging NO Serologic markers NIRS-not yet Direct Compartment Pressure Measure
41 MEASURING All compartments, not just anterior Within 5cm of fracture site
42 A-LINE
43
44 2003 Normal 0 5mmHg Absolute P > 20 30mmHg Delta P (DBP compartment P) < 30
45 2003 Normal 0 5mmHg Absolute P > 20 30mmHg Delta P (DBP compartment P) < 30
46 2003 Normal 0 5mmHg Absolute P > 20 30mmHg Delta P (DBP compartment P) < 30
47 2003 Tibia fractures Isolated >30mmHg vs Delta P As long as Delta P does not fall below 30, isolated P as high as 70mmHg tolerated
48 DIAGNOSIS UN-EVALUABLE EVALUABLE
49 EVALUABLE PAIN PALLOR POIKILOTHERMIA PARASTHESIA/PARALYSIS PULSELESSNESS
50 EVALUABLE Tense, swollen extremity + UNRELENTING PAIN PAIN AT REST PAIN ON PALPATION PAIN WITH PASSIVE STRETCH BAD PAIN.
51 Even in the evaluable patient
52 EVALUABLE Dynamic process, may progress Repeat clinical evaluation Repeat pressure measurement
53 TREATMENT SURGERY
54 ANTERIOR DEEP POSTERIOR LATERAL SUPERFICIAL POSTERIOR
55 MALLEOLUS FIBULAR HEAD
56 LATERAL ANTERIOR FASCIA
57 TIBIA MALLEOLUS
58 TIBIA DEEP POSTERIOR SUPERFICIAL POSTERIOR
59 POST-OP Negative Pressure Therapy Sequential attempts at closure One side better than none 1 week-continue versus graft
60 SUMMARY Common complication Pain is key clinical finding Liberal use of pressure monitoring Isolated P>20 30 mmhg Delta P<30 mmhg Watch for missed ANTERIOR and DEEP POSTERIOR
61 POST-OP Follow CKs Check muscle
62 MYOGLOBINURIA Muscle breakdown=myoglobin release Damages Renal Tubules ATN like Classic Dx: Urine dip+ but no RBC on micro
63 MYOGLOBINURIA Practical Dx: muscle enzymes Creatinine Phosphokinase Lactate Dehydrogenase Aldolase Enzyme CK > 5000 U/L or upgoing trend Treatment is inexpensive and low risk so err on side of caution
64 TREATMENT Crystalloid volume infusion UOP>1cc/kg Follow K and Phosphate levels Poor evidence to support either Bicarbonate or Mannitol infusion
65 SUMMARY ACS High index of suspicion in pts with risk factors and distended abdomen IAP>12mmHg= IAH IAP>20mmHg+organ dysfunction= ACS Hypotension, urine output, peak/plateaus Rx = medical +/- drainage +/- laparotomy
66 SUMMARY EXTREMITY CPMT Common complication Pain is key clinical finding Liberal use of pressure monitoring Isolated P>20-30 mmhg Delta P<30 mmhg Watch for missed ANTERIOR and DEEP POSTERIOR
67
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