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Culture Documents
Duret's haemorrhage is a haemorrhage into the occurs most commonly after a high speed motor
base of the pons or midbrain thought to result vehicle accident in which severe angular and
from disruption of the perforating arteries at the rotational forces are applied to the head
time of uncal herniation. Such brainstem present in almost 50% of patients with severe
haemorrhage almost always leads to death or TBI and in almost a third of those who die
vegetative survival a common cause of persistent negative
vegetative state of prolonged coma
Subarachnoid Haemorrhage
traumatic subarachnoid haemorrhage does not Aetiology of Secondary Brain Swelling
produce a haematoma or mass effect
it may be associated with post-traumatic
vasospasm
Cerebral Contusions
contusions are heterogenous lesions comprising
punctate haemorrhage, oedema and necrosis
and often associated with other intracranial
lesions
one or more contusions occur in 20-25% of
patients with severe TBI
contusions are most common in the inferior
frontal cortex and the anterior temporal lobes
where the surface of the inner table of the skull
is very irregular; they may result from shifting of
the brain over this irregular surface at the time
of impact
direct blunt force trauma to the head can
produce a contusion in the tissue underlying the
point of impact (coup contusion); if the head was
Management of Traumatic Brain Injury
in motion upon collision with a rigid surface, a
Prehospital Care
contusion may occur in the brain contralateral to
the point of impact the acutely injured brain is vulnerable to damage
from systemic hypotension, cerebral
because they evolve over time contusions may
hypoperfusion, hypercarbia, hypoxemia and
not be visible on initial CT scan
elevated ICP
local neuronal damage and haemorrhage lead to
care of the TBI victim should begin with
oedema which may increase over the next 24-48
evaluating and securing a patent airway and
hours
restoring normal breathing and circulation
depending on their size and location, they may
cause significant mass effect resulting in midline early intubation is probably of benefit; however,
the benefits of prehospital intubation have yet to
shift, transtentorial or subfalcine herniation
be demonstrated in a randomised controlled
initial signs and symptoms vary greatly
trial
depending on the size and location:
i. small contusions may cause no the patient should be sedated and
pharmacologically paralysed before intubation
symptoms or only mild headache
because irritation of the oropharynx causes
ii. contusions in eloquent area of the
transient hypertension and increased ICP
brain such as speech or motor areas
may cause focal deficits supplemental oxygen should be provided before
iii. large contusions, especially frontal intubation
ones, cause elevated ICP and coma therapeutic hyperventilation is inadvisable
unless neurological deterioration is clearly
Diffuse Axonal Injury evident during evaluation and transport;
refers to lacerations or punctate contusions at aggressive hyperventilation can cause cerebral
the interface between the gray and white ischemia via vasonconstriction
matter; such punctate contusions are thought to rapid fluid resuscitation and restoration of
result from the disparate densities of the grey normal blood pressure are critical in the
and white matter and the consequent difference prehospital setting because hypotension has
in centripetal force associated with a rotational been associated with doubling of mortality after
vector of injury severe traumatic brain injury
9 Critical Care Trauma
hypovoloemia is the likely mechanism and blood specimens are obtained and analysed for
therefore normal saline or Hartmanns should be glucose, electrolytes, full blood count, coags, and
infused as rapidly as possible cross match; serum toxicology may be
although preclinical studies suggested appropriate and women of childbearing age
hypertonic slain may be more effective for rapid should undergo a pregnancy test
volume resuscitation in head injured patients, a CT brain should be performed unless
several clinical trials have failed to demonstrate haemodynamic instability necessitates an
a benefit emergent laparotomy or thoracotomy; in these
all patients with a distracting injury (including circumstances, diagnostic burrholes may be
head injury) should be treated as if they have a appropriate in theatre if the patient has
cervical spine injury lateralizing neurological deficits particularly a
patients should be transported to a level I or II unilateral fixed and dilated pupil
trauma centre (ensuring the immediate
availability of neurosurgical care when the Definitive Treatment
patient arrives) critical to determining the severity of the brain
injury and the appropriate treatment are CT
Emergency Department Care findings combined with a reliable post-
upon arrival at the trauma centre, the resuscitation GCS score and assessment of pupil
emergency medical personnel should report size and reactivity
their prehospital assessment and management other determining factors include the size and
including mechanism of injury, stabilising location of the haematoma, the presence and
maneuvers, medications given, initial vital signs extent of an underlying contusion or brain
and GCS and haemodynamic stability during swelling and the results of neurological
transport examination
immediate management should proceed neurological deterioration suggests enlargement
according to the principles of the ATLS protocol of the hematoma and a new CT scan should be
which is designed to identify and treat performed promptly
immediately life threatening injuries haematomas less than 10mm thick that cause
the airway should be reassessed and the need to midline shift of less than 5mm can usually be
intubate the patient should be considered; for observed especially if they do not involve the
patients intubated in the field the proper middle cranial fossa; a haematoma that
position of the ET tube is verified both clinically compresses the temporal lobe is particularly
and radiologically as well as with end tidal CO2 ominous and can rapidly can uncal herniation so
when the airway is secured adequate that such lesions warrant a lower threshold for
oxygenation is confirmed using percutaneous evacuation
oxygen saturation and arterial blood gas analysis if a clot is small enough not to require
two large bore IV catheters are inserted to evacuation it should be monitored with frequent
provide sufficient venous access for high volume CT scans over the first several days after injury.
fluid resuscitation and isotonic crystalloid should Enlarging middle fossa haematomas large
be continued to replace volume loss enough to cause herniation do not always lead
life threatening injuries such as tension to a rise in ICP
pneumothorax, cardiac tamponade and overt patients with small or deep seated contusion
haemorrhage should be treated as they are without mass effect can be managed non-
discovered in the process of ATLS evaluation operatively initially. Contusion should be
a brief neurological evaluation is performed followed serially with CT scanning as there is a
including assessment of the GCS, pupils and 20-30% chance of significant enlargement in the
extent of extremity movements first 24-48 hours
careful inspection of the head should reveal a temporal contusion can enlarge to the point of
haemotympanum, periorbital or mastoid uncal herniation without a significant rise in ICP,
ecchymosis and CSF rhinorrhea or otorrhea thus, the threshold for evacuation of these
oxygen saturation is continually monitored and lesions should be lower
blood pressure frequently or continuously unilateral frontal or temporal lobectomies are
measured during the primary examination usually well-tolerated, do not cause measurable
a foley catheter is placed to help monitor the neurological deficit and provide space for the
fluid status and an orogastric tube is inserter to brain to swell
decompress the stomach
10 Critical Care Trauma
GCS
the second most important predictor of outcome
is the initial post-resuscitation GCS score. Among
patients with a severe closed head injuries in the
traumatic coma data bank study, good outcomes
occurred in 4.1% of those with an initial GCS of 3,
in 6.3% whose score was 4 and 12% whose score
was 5
Pupils
unilateral or bilaterally dilated pupils that are
unreactive to light usually reflect uncal
herniation and significant brainstem
compression and damage
several large clinical studies have found that
patients with bilaterally fixed and dilated pupils
had a greater than 90% likelihood of death or
vegetative state
Intracranial Hypertension
intracranial hypertension refractory to
medication is associated with a 43% mortality
rate and a 0% chance of functional outcome
Lesion Nature
Subdural haematoma
subdural haematoma is associated with the Extended Glasgow Outcome Scale
worst prognosis
one study found only 26% of patients with these
clots had a functional recovery
prognosis is related to how rapidly the clot is
evacuated with the best outcomes occurred in
patients who have surgery within 2 hours
Extradural haematoma
pose a much lower risk of mortality than SDH
because they are not usually associated with
underlying cerebral contusion and swelling
mortality depends a great deal on time to
surgery, untreated lesions can lead to uncal
herniation and death
14 Critical Care Trauma
Tension pneumothorax
Thoracic Trauma mediastinal structures are shifted away from the
General affected side and venous return to the heart is
thoracic trauma is responsible for 20% of all impaired due to vena caval distortion
trauma-related deaths and is 2nd only to head
trauma as a primary cause of death at injury Open pneumothorax
scenes results from a full thickness chest wall wound
although many thoracic injuries are not may be immediately managed by an occlusive
immediately life threatening they have the dressing secured on three sides, to prevent
potential for significant morbidity and mortality sucking of more air but allowing egress of the
pneumothorax until definitive wound closure
Initial Assessment and tube thoracostomy can be performed
General
ATLS provides the basic tenets for management 'Occult' pneumothorax
of all injured patients with the growing use of CT scanning in the
initial treatment involves: evaluation of trauma patients, small
a. primary survey pneumothoraces are often discovered
b. resuscitation treatment of these 'occult' pneumothoraces is
c. secondary survey not as well-defined as for the usual
d. diagnostic evaluation pneumothorax and observation may be
e. definitive care approprate even in the setting of positive
pressure ventilation
Airway
although the most typical threats to airway Haemothorax
control are neurological injury, facial trauma and General
foreign body obstruction, trauma to the larynx, can range from small and asymptomatic to
trachea or bronchus may complicate of preclude massive and immediately life threatening
airway control a small haemothorax can be difficult to
appreciate on a chest radiograph (in the upright
Breathing position blunting of the costophrenic angle
thoracic trauma commonly causes life- requires 200-250ml of blood while in the supine
threatening breathing problems including position, there may only be a subtle haziness on
i. pneumothorax the affected side)
ii. haemothorax
iii. pulmonary contusion Massive haemothorax
iv. flail chest a massive haemothorax is usually the result of a
major vascular injury and is life threatening
Circulation
thoracic trauma may also cause life-threatening Treatment
circulation problems including: immediate return of 1500ml of blood or
i. tension pneumothorax continuing loss of 250 ml/hr for 3 hrs is an
ii. cardiac tamponade indication for thoracotomy
iii. great vessel injury haemothoraces with blunt chest wall trauma can
pose special challenges and in particular cases
Pneumothorax one might consider arteriographic embolisation
General of intercostal bleeders
pneumothorax is a common sequela of thoracic one should be suspicious of an initial high
trauma volume loss which suddenly ceases and repeat
visceral pleural disruption due to penetrating chest radiography should be performed to
trauma, blunt shearing or lacerations from exclude blockage of the ICC
fractured bones, allows air to enter the pleural
space as negative intrapleural pressure is created Chest Wall Injury
during inspiration Rib fractures
are estimated to occur in 10% of patients
Physical findings presenting for evaluation by a trauma service
include decreased breath sounds, and are usually (90%) associated with other
hyperresonance to percussion and decreased injuries
expansion of the chest wall on the affected side
15 Critical Care Trauma
multiple rib fractures, fractures of the 1st and positive end-expiratory pressure should be
2nd rib and scapular fractures signify high- minimised post-operatively where possible
energy injuries
single rib fractures in young patients are Esophageal Injury
generally of little consequence; however, rib blunt force mechanisms may cause a sudden rise
fractures in elderly patients can lead to in intraluminal pressure or the upper esophagus
diminished pulmonary function and disastrous may be crushed between the trachea and a
infectious complications vertebral body; however, esophageal injury is
patients over 65 have a 2-5 fold increase the result of penetrating trauma
morbidity and mortality compared to younger pneumomediastinum should raise the suspicion
patients with similar injuries and in the elderly of this injury
Bulger et al found that each additional rib options for investigation include esophagoscopy
fracture increases mortality by 19% and or if the patient is awake, barium swallow
pneumonia by 27% if injury is identified within 24 hours it can be
pain control is the key factor in management of primarily repaired; otherwise drainage and
these injuries with evidence demonstrating that delayed repair is employed
epidurals are superior to PCAs for this indication;
intercostal blocks are another alternative Lung Injury
Pulmonary contusion
Flail Chest a common problem in severely injured
two or more ribs fractured in two or more places multitrauma patients
produces a flail segment of the chest wall which may result from a direct blow, shearing or
moves paradoxically bursting at an interface or transmission of a
mechanical effects on respiration are related to shock wave
the size of the flail segment; however, pathophysiologic changes fundamentally
underlying pulmonary contusion rather than involves haemorrhage with surrounding oedema
mechanical effect of the flail is usually the major and manifests clinically with hypoxia,
cause of respiratory compromise hypercarbia and increased work of breathing due
treatment is supportive with endotracheal to V/Q mismatch and decreased pulmonary
intubation and positive pressure ventilation compliance
sometimes required may not appear radiographically on initial
surgical stabilisation of the flail segment is not presentation but are usually seen by 6 hours
routinely performed but may be considered in post injury and are seen more readily on CT
particular circumstances (overall its benefits are chest in the early stages
marginal) the degree of pulmonary dysfunction usually
peaks at 72 hours and generally resolves within 7
Sternal fracture days in the absence of nosocomial pneumonia
early series of sternal fracture described the an admission PF ratio of <250 predicts a poor
'steering wheel syndrome' as the most common outcome
cause of sternal fracture. In these series, post-traumatic pulmonary pseudocysts are
associated blunt cardiac injury was common and cavitatory lesions that occur in 3% of
thus sternal fractures were thought to be parenchymal lung injuries, may generally cause
harbingers of significant occult thoracic injury few symptoms and resolve in 2-4 months
recent series of sternal fractures occurring in the
context of 'selt belt syndrome' have determined Pulmonary Laceration
that associated injuries are rare in this context pulmonary laceration may be caused by
penetrating trauma, blunt shearing of the ends
Tracheobronchial Injury of fractured bones
uncommon but should be executed in the the typical clinical presentation is of
presence of cervical subcutaneous emphysema, haemopneumothorax
pneumomediastinum or pneumothorax with a bleeding is usually self limiting and a chest tube
persistent air leak is the only required treatment
although CT may reveal some injuries, the of the 10% requiring thoracotomy,
preferred diagnostic test is bronchoscopy approximately 20% need a lung resection
laryngotracheal injuries often require
tracheostomy as an adjunct to repair whereas
tracheal and bronchial injuries may be repaired
without tracheostomy
16 Critical Care Trauma
Location of Injury
almost all survivors have isolated injuries to the
thoracic cavity
cardiac injuries have the highest survival rate
(single>multiple chambers)
penetrating abdominal trauma may benefit from
cross clamping the aorta but thoracotomy for
multiple blunt trauma has an almost universal
poor outcome
18 Critical Care Trauma
Correction of acidosis
acidosis is generally the result of global
ICU Management of Abdominal Trauma hypoperfusion and should correct with
General restoration of circulatory volume and
admission to ICU necessitates reevaluation of haemoglobin
the patient by repeating the primary and
secondary surveys Correction of Coagulopathy
repeat primary survey is required because clotting factors function best at normal
i. transport may have dislodged temperature and normal pH
equipment standard coagulation tests may be normal in the
ii. significant time may have elapsed since lab at 37 degrees despite significant
the initial primary survey coagulopathy in the hypothermic patient
secondary survey is required because coagulopathy may also be a result of dilution in
i. it may have been interrupted due to massive transfusion or disseminated
the need for urgent operation intravascular coagulation
ii. patient may have been transferred to calcium is bound by citrate, a preservative in
ICE due to decline in clinical status packed red cells and needs to be aggressively
iii. 10% of trauma patients have injuries replaced as it acts in the clotting cascade and is
that are missed during the initial required for normal contractive function of the
evaluation heart and circulatory system
iv. 25% of abdominal injuries are
undetected at the time of presentation Delayed Complications
delayed complications from either known or
Admission for non-operative management of Solid Organ unsuspected intra-abdominal injuries generally
Injury manifest as sepsis
non-operative management consists of: the possibility of missed hollow viscous injury is a
changes in physical examination findings, major concern during the nonoperative
haemodynamic status (including tachycardia) or management of patients
transfusion should be promptly communicated when solid organ injuries are indentified the risk
to the trauma surgeon as any clinical of hollow viscus injury increases so that 6% of
deterioration may necessitate immediate patients with one solid organ injury have a viscus
angiography or operation injury, 22% with two solid organ injuries have a
viscus injury and 33% of patients with three solid
Admission after Damage Control Laparotomy organ injuries have a viscus injury
General
'damage control' refers to urgent abdominal
exploration with the basic goal of controlling
massive bleeding and preventing ongoing
peritoneal contamination
after 'damage control' patients often arrive in
the ICU hypothermic, acidotic and coagulopathic.
ICU goal is to correct these abnormalities to
allow return to theatre for definitive operation
as required
failure to correct acidosis of coagulopathy
suggests ongoing bleeding which may require
return to theatre