Michael Avant, M.D. The Children s Hospital of GHS

Transcription

1 Michael Avant, M.D. The Children s Hospital of GHS

2 OVERVIEW ER to ICU Transition Early Management Priorities the First 48 hours Organ System Support Complications

3 THE FIRST 48 HOURS Communication Damage Control Surgery Ongoing Resuscitation Organ System Support Missed Injuries Manage/Prevent Complications

4 Communication: Yes, It s really that important! Joint Commission says: 10% of trauma fatalities preventable 67% of these due to communication errors Patient handoff critical The Handoff (Miami data) 24% had missing injuries in ICU record 50% had discrepancies in documentation

5 Communication: ER to ICU Handoff No standardization Poorly defined responsibilities Many distractions Differing clinical priorities among services Novice trainees Medical hierarchy Solutions Flattening of medical hierarchy Pilot/Co-Pilot model Trauma checklist

6 ICU TRAUMA CARE General Neurologic Respiratory Cardiovascular Hematologic Orthopedic

7 ICU Trauma Care : General Hyperglycemia Early enteral nutrition Surgical timing Infection surveillance fever, wounds Tertiary survey Family communication Ongoing monitoring Prevention of complications & secondary injury

8 ICU Trauma Care: Respiratory Lung protective strategy 6 8 ml/kg tidal volume Higher PEEP Avoid hyperventilation in TBI Avoid hypoxia Pulmonary contusion Consider TRALI & TACO Sedation of mechanically ventilated pt

9 ICU Trauma Care : Sedation Rapid acting, Short duration Propofol 2-3 mg/kg bolus followed by mcg/kg/min infusion Midazolam mg/kg Fentanyl 2 3 mcg/kg Ketamine 1 2 mg/kg Longer duration Lorazepam Morphine 0.1 mg/kg mg/kg Infusions propofol, midazolam, fentanyl Neuromuscular blockade

10 ICU Trauma Care: Neurologic Traumatic brain injury (TBI) most common cause of pediatric mortality Primary vs. secondary injury Hypoxia, hypotension, ischemia Avoidance of secondary injury Critical! First hours Single episode of hypotension doubles mortality 4x risk of poor neurologic outcome Goals > 90% O 2 sat or PaO 2 > 60 mmhg Systolic BP > 75 th % PaCO mmhg Consider abusive head trauma

11 GOALS OF NEUROLOGIC SUPPORT Avoid secondary injury Mitigate cerebral edema & control ICP Seizure control Avoid hyperventilation Support hemodynamics (CPP) Avoid/Tx hyperthermia Treat hyperglycemia

12 Neurologic : Seizure Prophylaxis Seizure Risks young age, pre-hospital hypoxia, non-accidental trauma, depressed skull fracture, penetrating injury, subdural hemorrhage 70% occur within first 24 hours Non-convulsive seizures common in peds Consider EEG monitoring Treatment Benzodiazepines Keppra (levetiracetam) Fosphenytoin barbituates

13 Neurologic : ICP Control ICP Monitoring GCS < 8 Abnormal head CT Abnormal neuro exam Sedation Maintain ICP < 20 cm H 2 0 Osmolar therapy Sedation /analgesia/nmb CPP management Induced hypothermia ( C o ) Consider reimaging Decompressive craniectomy

14 ICP Control : Osmolar Therapy Mannitol Hypertonic Saline (3%) Long history of use Little clinical data Rapid onset Recent clinical use Substantial recent data Sustained response grm/kg 3 5 cc/kg and/or cc/kg/hr Diuresis & hypovolemia Hyperchloremic acidosis, thrombosis if Na + >170 Follow serum Osm Follow serum Na + (< 170) Out of favor (except emergent) Currently recommended

15 Hemodynamic Support Avoid hypotension!! Lactate and/or base deficit monitoring Superior to BP & UOP monitoring Keep lactate < 1.5 & BD > -2 High mortality if acidosis remains > 48 hours CPP Management (CPP =MAP ICP) Adults 6 17 yo 0 5 yo mmhg > 50 mm Hg > 40 mm Hg Consider blunt cardiac injury Arrhythmia Unresponsive hemodynamics

16 ICU Trauma Care: Hematologic Aggressive use of blood products Minimize crystalloid Massive transfusion protocol 1:1:1 PRBC:FFP:Platelets PT/PTT vs. TEG/ROTEM monitoring New data on fibrinolysis Alternative therapies Tranexamic acid rfviia Fibrinogen concentrate

17 Fibrinolysis Definition: Process that restores flow to injured areas by dissolving fibrin clots formed by the coagulation cascade Plasmin degrades Fibrin which worsens coagulopathy Common early in severe trauma CRASH-2 Study : Tranexamic acid should be given within 3 hours of injury Tranexamic acid inhibits fibrinolysis by blocking plasminogen(prevents degfradation of existing clots) TEG monitoring????

18 MISSED INJURIES 6.5% of all trauma deaths due to undiagnosed injuries Types of missed injuries Fractures facial, extremity Spinal Vascular Abdominal Risk Altered mental status or sedation Lack of early symptoms Unresponsive to resuscitation Tertiary survey Family communication

19 ICU Trauma Care: Complications Hypothermia coagulopathy Transfusion Related Acute Lung Injury(TRALI) Transfusion Associated Circulatory Overload (TACO) Rhabdomyolysis Hyper/ Hypo kalemia Hypocalcemia Intra-abdominal hypertension Bladder pressure monitoring Infection

20 FROM ER TO ICU SUMMARY Communication Monitor need for ongoing resuscitation Lactate/Base deficit Minimize crystalloid 1:1:1 Transfusion ratio Lung protective strategy Avoid hypotension, hypoxia, ischemia Hypertonic saline recommended over Mannitol Be aware of fibrinolysis ICP control guidelines Tertiary survey Family communication