BCC4: Michael Parr on ICU - Surviving Trauma Guidelines
Upcoming SlideShare
Loading in...5
×

Like this? Share it with your network

Share

BCC4: Michael Parr on ICU - Surviving Trauma Guidelines

  • 1,166 views
Uploaded on

Michael Parr, director of Liverpool ICU in Australia, speaks about "Surviving Trauma Guidelines". He does so through the use of an interesting case of a patient admitted to ICU following a MVA.......

Michael Parr, director of Liverpool ICU in Australia, speaks about "Surviving Trauma Guidelines". He does so through the use of an interesting case of a patient admitted to ICU following a MVA. This educational podcast was recorded at BCC4.

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
1,166
On Slideshare
392
From Embeds
774
Number of Embeds
4

Actions

Shares
Downloads
10
Comments
0
Likes
1

Embeds 774

http://intensivecarenetwork.com 440
http://www.intensivecarenetwork.com 331
http://www.slideee.com 2
http://icn.wpengine.com 1

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. ICU-Surviving Trauma Guidelines
  • 2. Brain trauma foundation
  • 3. Levels of evidence Class 1: Things I believe Class 1 : Things I believe despite the data Class 1: Randomised controlled clinical trials that agree with what I believe Class 2: Expert opinion that agrees with me Class 3: Other data that agrees with me Class 4: Randomised controlled clinical trials that don't agree with what I believe Class 5: What you believe and I do not
  • 4. 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
  • 5. 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?
  • 6. 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
  • 7. 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
  • 8. 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)
  • 9. What Now?
  • 10. Role for ICU • Optimisation of systems: Haemodynamics, oxygenation/ventilation, renal function, nutrition • Correct hypothermia, coagulopathy and acidosis (the TRIAD) • Monitoring –BP, IAP, ScvO2, UO
  • 11. Rules of Intensive Care • Assume nothing • Trust no one • Give oxygen (enough, not too much) • History (PMH and medications) • Examination • ALL investigations and imaging
  • 12. 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.
  • 13. 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
  • 14. – 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
  • 15. What fluid? How much?
  • 16. 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
  • 17. 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.
  • 18. Time to re-evaluate • Vital signs • Clinical examination • Blood loss • Urine output • Repeat ABG (lactate and BD), FBC and coagulation
  • 19. RAPTOR Resuscitation with Angiography, Percutaneous Techniques and Operative Repair
  • 20. Clinical examination is an inaccurate predictor of intra-abdominal pressure. World Journal of Surgery 2002;26:1428-1431.
  • 21. 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.
  • 22. 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
  • 23. 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
  • 24. Traumatic rupture of aorta Diaphragmatic rupture Bowel injury Fractures / ligament damage Nerve injury
  • 25. A patient at risk??
  • 26. 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).
  • 27. 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).
  • 28. 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
  • 29. 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