ICU treatment of the trauma patient Intensive Care Training Program Radboud University Medical Centre Nijmegen
Christian Kleber Surgical Intensive Care Unit - The trauma surgery Perspective Langenbecks Arch Surg 2011;396:429-446
ICU treatment after trauma Resuscitation Restoration of normal physiology Organ dysfunction and replacement phase Recovery phase Regeneration phase 0 24 48 Close cooperation essential
Mortality after trauma N = 2944 Demetriades D. J Am Coll Surg 2005;201:343-348
Time of death depends on mechanism N = 2944 Penetrating Blunt Demetriades D. J Am Coll Surg 2005;201:343-348
Still a major problem! Even in high-resource trauma centres ⅓ of patients with ISS > 24 die ⅓ of patients with massive haemorrhage die ⅓ of patients with very severe TBI die Focus shift towards longterm functional outcome Brohi K. Curr Opin Crit Care 2011;17:515-519
Effective early interventions Massive haemorrhage Definitive control of bleeding Permissive hypotension Haemostatic resuscitation Severe TBI Early intubation, normocapnia, advanced neurocritical care and prompt neurosurgical intervention Complex limb injuries Damage Control Strategy Early revascularization (<<< 6 hrs), pain control, infection prevention Brohi K. Curr Opin Crit Care 2011;17:515-519
ACIDOSIS COAGULOPATHY H Y P O T H E R M I A HYPOTHERMIA! Triangle of Death Angele MK. Crit Care 2008;12:218
Damage Control Surgery Stop bleeding and prevent ongoing contamination Resuscitation in the ICU Definitive surgical therapy ± abdominal wall closure Focus on physiological reserve of patient
When to apply a damage control strategy? Penetrating trauma or complex vascular injury Hemodynamic instability Coagulopathy, hypothermia, acidosis Transfusion of > 10 units PRBC Operative time > 90 min or associated lifethreatening extra-abdominal injury
ICU priorities Maintain normovolemia & tissue perfusion Maintain normothermia Correct coagulopathy Treat metabolic acidosis Recognise early complications that need reexploration in stead of definitive surgery after 24-48 hours
Hemodynamic stabilisation Based on end-organ perfusion (SvO2 > 65-70%, lactate, urine production) Resuscitation fluid based on ph, Hb, coagulation profile (Curr Opin Anesthesiol 2011;24:202-208) Invasive monitoring with inadequate response to fluid resuscitation Echocardiography extremely useful to diagnose other reasons for hypotension
ScvO2 after trauma N = 50 Difference in ScvO2 following resuscitation to MAP 70 mmhg Hosking C. Acta Anaesthesiol Scand 2011;55:713-721
Persistent hypovolemia Pericardial effusion/tamponade? Myocardial contusion / depression Acute aortic valve regurgitation
Early complications that need re-exploration Persistent bleeding (> 2U/h for 3 hrs) - consider selective embolization GI tract perforation with worsening septic shock Abdominal compartment syndrome (IA pressure > 20 mm Hg associated with new organ failure)
ACS - predisposition Severe abdominal injuries Spillage of intestinal content Primary fascial closure under tension Intra-abdominal packing for coagulation Massive transfusion with bowel edema Failure to control bleeding Overzealous fluid resuscitation Up to 5-10% after damage control surgery
Incidence ACS decreasing N = 81 Trauma/shock after trauma 12-15 No ACS 16-20 21-25 > 25 Mean IAP or APP not correlated with development of MODS Balogh ZJ. Arch Surg 2011;146:938-943
Abdominal compliance Pressure Abdominal wall compliance decrease due to hematoma muscle activity, edema Normal Volume
ACS - Ventilation Plateau pressure Bladder pressure Tidal volume mm Hg and cm H2O Decompression 50 350 200 400 40 30 20 10 0 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 Hours
ACS - Circulation CVP Decompression Bladder pressure 50 Cardiac output 7.2 3.8 8.4 Lactate 2.1 12 4.6 40 mm Hg 30 20 10 Diuresis 220 0 20 200 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 Hours
ACS and preload R = -0.64 R = 0.86 Cardiac output (ml/min/kg) Cardiac output (ml/min/kg) CVP (mm Hg) ITBV (ml/kg CVP and PCWP do not reflect preload in ACS Schachtrupp A. J Trauma 2003;55:734-740
ACS and ICP ICP CPP Bladder pressure 100 Decompression 75 mm Hg 50 25 0 0 2 4 6 8 10 12 15 16 18 20 22 24 26 28 30 Hours
Treatment Non-surgical Evacuate intraluminal contents Evacuate extraluminal contents Sedation and neuromuscular blockers Correction of positive fluid balance Surgical - with progressive MODS and failure of conservative measures
Medical treatment Prevention with IAP monitoring and avoidance of excessive resuscitation with crystalloids Remove excess of fluids with diuresis/hemofiltration/paracentesis if tolerated Relax abdominal wall with sedatives and neuromuscular blockade while avoiding opiates Reduce gaseous intestinal distention with prokinetics, nasogastric decompression, rectal drainage Proper positioning with avoidance of prone position, semirecumbent position and reverse-trendelenburg position
Final remarks Close cooperation between surgeon, radiologist, anaesthesiologist, intensivist and ICU nurses necessary for the best results Focus on patients physiological reserve