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1 Critical Care Trauma

Principles of Trauma Assessment iii. Circulation


Definition key clinical findings are: collapsed or
Objectives of initial evaluation of the patient are: distended neck veins, signs or
i. stabilisation of the trauma patient tamponade, external sites of
ii. identification of life-threatening injuries and haemorrhage
initiation of adequate supportive therapy key conditions identified are:
iii. efficient and rapid definitive therapy hypovolemia, cardiac tamponade,
external haemorrhage
In trauma centres a team of providers evaluates patients key treatment is: IV access, fluid
who are critically injured and simultaneously performs resuscitation, compression of sites of
diagnostic procedures (this parallel processing approach bleeding
can dramatically reduce the time to assess and stabilise iv. Disability
the patient with multiple injuries) key clinical conditions are: decreased
level of consciousness, pupillary
Key Elements are: asymmetry, gross weakness
1. Primary Survey key conditions identified are: serious
2. Resuscitative phase head and spinal cord injury
3. Secondary Survey key treatment is: definitive airway of
4. Definitive therapy indicated, emergency treatment of
raised ICP
Initial Assessment v. Exposure and Control of immediate environment
General: expose patient and prevent
involves protocol of primary survey, hypothermia
resuscitation, secondary survey and either
definitive care (ATLS system) Other procedures:
absolute diagnostic certainty is not required to Several monitoring and diagnostic adjuncts occur in
treat critical conditions identified early in the concert with the primary survey:
process and where resources are limited I. ECG and ventilatory monitoring and continuous
subsequent steps should not be performed until pulse oximetry
life-threatening conditions in the earlier II. decompress stomach with NG or OG tube once
symptoms are addressed airway is secured
III. insert a foley catheter during resuscitation phase
Primary survey: (foley catheter placement is contraindicated if
i. Airway (ability of air to pass unobstructed to the urethral injury is evident as identified by blood at
lungs); critical findings include: the meatus, ecchymosis or scrotum or labium
obstruction of the airway due to direct majora or high riding prostate- retrogade
injury, oedema, foreign body or urethrogram is required for these patients)
inability to protect the airway because
of depressed level of consciousness Resuscitation and Comprehensive Assessment
key treatment is: establishment of Resuscitation phase:
airway continues throughout primary and secondary
ii. Breathing (ability to ventilate and oxygenate); survey and until treatments are complete
key clinical findings are: fluids are required to sustain intravascular
absence of spontaneous ventilation, volume, tissue and organ perfusion and urine
absent or asymmetrical breath sounds, output
dyspnea, hyperresonance, dullness, administer blood for hypovolemia that is
gross chest wall instability or defects unresponsive to crystalloid boluses
that compromise ventilation end points are normal vital signs, absence of
key conditions to identify are: blood loss, adequate urine output and no
pneumothorax, endotracheal tube evidence of end organ dysfunction; blood lactate
malposition, tension pneumothorax, and base deficit on an ABG may be helpful in
haemothorax, sucking chest wounds, patients who are severely injured
flail chest
key treatment is: chest tube
2 Critical Care Trauma

Secondary Survey: Special Situations


identify all injuries by a head to toe examination Burns:
exclude FATAL TRAUMA extensive lavage of area of chemical burns is
o Flail chest required to stop further burning
o Airway compromise escharotomies may be required for full thickness
o Tamponade burns of chest or extremities
o Air leaks early intubation is required for suspected airway
o Lung contusion burns or inhalational injury
o Tracheal injury patients with large burns require large volumes
o Ruptured diaphragm of crystalloid which need to be administered
o Aortic disruption early
o Unseen haemorrhage
o Myocardial injury Cold injuries:
o Any neurological abnormality dominant imperative is rapid rewarming with
if the patient is awake collect critical data warm IV fluids
including AMPLE
High Voltage Electricity:
Imaging and Laboratory Studies most tissue injury will not be evident on physical
Trauma series: examination
CXR identifies haemothorax, pneumothorax massive myonecrosis and damage to soft and
pulmonary contusion bone may be concealed under normal skin
AP pelvis can confirm presence of significant need low threshold for measuring compartment
pelvic fracture pressures and careful monitoring of urine for
lateral c-spine can identify non-survivable neck myoglobinuria
injury provide direct cardiac monitoring to look for
direct injury or arrhythmia secondary to
CT scan: hyperkalemia
CT brain for neurological injury
CT neck for neck injury Glasgow Coma Score
CT chest, abdo, pelvis using oral and IV contrast General
to identify injuries to solid organs and pelvic and a neurological scale which gives an objective way
retroperitoneal bleeding of recording conscious state; originally
CT aortogram developed to assess level of consciousness after
head injury its use is now widespread
Spine X-rays: originally published in 1974 by Jennet
if likelihood of spinal injury is low then imaging score correlates with outcome in head injury
can be deferred until resuscitation phase is well GCS is part of several scoring systems including
underway APACHE II, SAPS II & SOFA that predict outcome
lateral C-spine helps identify 85% of c-spine in severe illness
fractures its major strengths are that it has proved to be
consistent between expert and non-expert
Angiography: observers and has been adopted worldwide
can be both diagnostic and therapeutic
commonest indications are: GCS:
i. suspected aortic injury comprise E, V & M (eyes, motor, verbal)
ii. pelvic or retroperitoneal bleeding originally score was out of 14 with no
iii. organ specific embolisation differentiation between withdrawal and
abnormal flexion
Lab studies:
i. X-match Eye responses:
ii. ABG 4 eyes open spontaneously
iii. baseline Hb 3 eye open to speech (a sleeping person who
iv. urine dipstick for hematuria wakes up scores 4)
v. electrolytes, coags, cell counts 2 eye opening to pain
1 no eye opening
3 Critical Care Trauma

Verbal responses: the bony protection afforded to the airway by


5 Orientated the sternum and mandible and death from
4 Disorientated asphyxia at the accident scene account for the
3 Inappropriate rarity of the injury
2 Incomprehensible
1 None Mechanism of Injury
Blunt injury:
Motor responses: common causes include motor vehicle accidents
6 Obeys commands where the extended neck impacts with the
5 Localises (eg hand crosses midline or gets steering wheel or dashboard
above clavicle to supra-orbital pressure) the 'clothes line injury' occurs when a cyclist or
4 Withdraws horserider collides with a cable or wire causing
3 Abnormal flexion (decorticate response) direct injury to the upper airway; assaults and
2 Extension (decerebrate response) strangulation account for the remainder of
1 None injuries
direct blows are more likely to injure the
Interpretation: cartilages of the larynx while flexion/ extension
Severe, GCS 3-8 injuries are most commonly associated with
tracheal tears and laryngotracheal transection
Moderate, GCS 9-12
Minor GCS 13-15 larynx above the cricoid is injured in 35%
manifesting as oedema, contusions,
Paediatric GCS haematomas, lacerations, avulsion and fracture
General: dislocation, most commonly of the thyroid and
arytenoid cartilages
GCS has limited applicability (especially in a child
below 36 months of age) where verbal the cricoid cartilage itself is injured in 15% which
performance of a healthy child would be may cause recurrent laryngeal nerve dysfunction
expected to be poor the cervical cartilage itself is injured in 45% with
tracheal transection occurring most often at the
Eye responses junction of the cricoid and trachea. Oedema fluid
4 spontaneous and air dissecting within submucosal layers of
the larynx and trachea may cause airway
3 to speech
obstruction. Air in the soft tissues can cause
2 to pain
epiglottic emphysema and narrowing of the
1 None
supraglottic airway in which case straining,
talking and coughing may worsen the oedema
Verbal responses
5 infant coos or babbles (normal activity)
Penetrating Injury
4 infant is irritable or cries continually
usually results from stab and gunshot wounds
3 infant cries to pain
the anterior triangle of the neck is the most
2 infant moans to pain common involved stab wounds
1 no verbal response the larynx is injured in 1/3 of those with upper
airway injuries
Motor responses
6 infant moves spontaneously or purposefully Associated injuries:
5 infant withdraws from touch common associations with blunt laryngotracheal
4 infant withdraws from pain injury include:
3 abnormal flexion to pain of those with penetrating neck trauma, major
2 extension to pain vascular injuries (carotid, jugular, subclavian, and
1 no motor response vertebral arteries) occurs in 25-50%, pharyngeal
and or esophageal injuries occur in 30%, neural
Laryngeal and Tracheal Injury injury (spinal cord, brachial plexus) in 12% and
General apical thoracic injury in 10%
direct trauma to the airway is rare accounting for
less than 1% of traumatic injury seen in most
major centres
4 Critical Care Trauma

Assessment Airway Management


General airway management in patients with neck
definitive investigation and management depend trauma is based upon a high index of clinical
on the airway status and presence of associated suspicion for cricoid or cervical tracheal injuries.
injury Attempts at endotracheal intubation in patients
the degree of injury is not readily assessable on with unsuspected cricoid injuries can be
the basis of any one clinical symptom or sign and disastrous. Cricoid pressure or the attempted
delayed diagnosis is common passage of an endotracheal tube may dislocate a
fractured crocoid cartilage and/or entirely
Clinical features: disrupt a partial tracheal transection, producing
i. symptoms complete airway obstruction.
respiratory distress the equipment and personnel required to
hoarseness perform an immediate tracheostomy must be
dysphonia present prior to manipulation of an injured
cough airway
stridor, noisy breathing positive pressure ventilation can exacerbate air
dysphagia leaks and rapidly worsen symptoms from
ii. signs pneumothorax, pneumomediastinum and air
abnormal laryngeal contour dissecting around airway structures. Whenever
subcutaneous emphysema possible, the patient should be permitted to
cervical ecchymosis breathe spontaneously
haemoptysis rapid induction of anesthesia and neuromuscular
blockade can rapidly produce loss of the airway
Investigation and the inability to provide positive pressure
Plain radiography may demonstrate ventilation
i. air in soft tissues attempts at direct laryngoscopy or intubation
ii. pneumomediastinum over a flexible bronchoscope may be futile
iii. pneumothorax because of bleeding within the airway or
iv. cervical spine fracture distortion of anatomuc structures. The danger
also exists that flexible bronchoscopy may
CT scanning demonstrates occlude the airway or precipitate airway
i. fractures of the cartilages obstruction in patients with critical airway
ii. haematomas stenosis
under ideal circumstances, pre-oxygenation
it is used in stable patients with laryngeal followed by awake flexible bronchoscopy may
tenderness, endolaryngeal oedema and small permit evaluation of airway injuries and safe
haematomas endotracheal intubation
Prior induction of general anesthesia, using a
Fibre Optic Laryngotracheostomy potent inhalation anesthetic such as sevoflurane,
can demonstrate vocal cord dysfunction, while maintaining spontaneous ventilation, may
integrity of the cartialgenous framework and be appropriate in some patients. This approach
laryngeal mucosa can permit rigid laryngoscopy and rigid
bronchoscopy while maintaining spontaneous
Rigid Laryngoscopy ventilations. These techniques may be preferable
can be used when adequate visualisation is not when bleeding or debris obscure the airway,
achieved with fibreoptics making fibreoptic examination impossible. If
endotracheal intubation appears unwise and the
Others: patient is unstable or the airway is lost,
pharyngo-oesophagoscopy, contrast studies, immediate tracheostomy is the only appropriate
open exploration and angiography may be choice
required to exclude aerodigestive tract and when the trachea itself is injured, it is preferable
major vascular injuries to conserve normal trachea by placing the
tracheostomy through the damaged area. This
will facilitate subsequent surgical repair of the
trachea
5 Critical Care Trauma

Spinal Injury Assessment of Head Injury


Cervical General
Hyperflexion patients with head injuries can be divided into
Hyperflexion and rotation those with high-risk indicators and those with
Hyperextension minor head injuries. Clinical rules exist to help
Hyperextension and rotation determine which patients with minor head
Vertical compreesion or burst injury injuries require CT scans
Lateral flexion
Direct shearing Definite indications for imaging
Penetrating High risk factors that clearly necessitate imaging include:
Other 1. loss of consciousness for more than 5 minutes
Thoraco-lumbar 2. depressed or decreasing level of consciousness
Compression fractures 3. focal neurologic findings
4. seizure
Burst fractures
5. failure of mental status to improve over time in
Seat belt type injuries
an alcohol-intoxicated patient
Fracture dislocation
6. penetrating skull injuries
7. signs of a basal or depressed skull fracture
Specific Injuries
Level Injuries
What constitutes a minor head injury?
C1 Jefferson fracture - blow-out injury of
there is no precise definition of what constitutes
the ring with anterior and posterior
a minor head injury
arch fractures
normal neurological examination has been used
C2 Dense fractures; type A; type B - by some experts to define a minor head injury
base of dens; type C - subdental; even with brief LOC and post-traumatic amnesia
suspect if >5mm between
GCS of 15 at time of assessment used by others
anterior arch of C1 and the
GCS of 13 or higher has also been used as
odontoid peg
definition (although 40% with a GCS of 13 have
Hangman's fracture - bilateral
an abnormal CT)
arch fracture
C3-T1 Subluxation (> 25% loss of Clinical criteria for imaging in patients with minor head
alignment) or dislocation (>50% injuries
loss of alignment between New Orleans Criteria for CTB after minor head injury:
adjacent vertebrae) - suspect if 1. headache
increased prevertebral soft tissue 2. vomiting
swelling 3. age over 60 years
Clay-shoveller fracture - avulsion 4. drug or alcohol intoxication
of C6, C7 or T1 spinous process 5. deficits in short-term memory
Thoracolumbar Wedge fracture - >2mm 6. evidence of trauma above the clavicles
difference between the anterior
and posterior height of the Canadian CT head rules:
vertebral body (may be normal at defines minor head injury as 'defined witnessed
T11-L1) LOC, definite amnesia or witness disorientation
Chance fracture - oblique or in patients with a GCS of 13-15'
horizontal split of spinous process the rules are:
and neural arch extending to the 1. GCS of less than 152 hours after the
superoposterior vertebral body/ injury
disc 2. suspected open or depressed skull
Horizontal fissure fracture - fracture
variant with fracture line 3. more than two episodes of vomiting
extending to the anterior 4. physical evidence of basal skull
vertebral body fracture
Thoracic fractures may be 5. age>65 years
accompanied by paravertebral in addition there were two 'medium-risk' factors
haematomas, producing for predicting brain injury on CT:
mediastinal widening and an 1. amnesia for events that happened
apical cap more than 30 minutes prior to injury
6 Critical Care Trauma

2. dangerous mechanism Primary injury:


i. pedestrian struck by motor i. contact forces
vehicle produce focal injuries such as skull
ii. occupant ejected from motor fractures, contusions and extra or
vehicle subdural haematomas
iii. fall from higher than 3 feet ii. inertical forces
or 5 stairs result from the brain undergoing
the five 'high risk' criteria were 100% sensitive in acceleration or deceleration and can
a study of over 3000 patients occur without head impact

Other indications for CT brain


Alcohol-induced patients:
alcohol intoxicated patients have a prevalence of inertial forces can produce focal or
intracerebral injury on CT scans of 2.4-8.4% diffuse brain injuries: pure
translational acceleration leads to focal
Patients with coagulopathies: injuries such as contrecoup contusions,
patients taking warfarin should be worked up intracerebral haematomas and
aggressively perhaps with overnight observation subdural haematomas, whereas,
and repeat scanning (abnormal clotting predicts rotational or angular acceleration,
delayed brain injury on CT) common with motor vehicle accidents
leads to diffuse injuries
Patients with shunt-treated hydrocephalu:
aggressive diagnostic work-up is indicated Secondary injury:
post-traumatic ischaemia initiates a cascade of
Infants and children: metabolic events that lead to the surplus
infants have been reported to develop production of oxygen free radicles, excitatory
intracranial haematomas despite normal initial amino acids, cytokine and other inflammatory
examinations and CT scans; symptoms such as agents
vomiting and seizures have poor specificity and post traumatic non-ischaemic events such
sensitivity increase in intracellular free calcium via receptor
a number of studies show that 0.4-1.5% if gated or voltage gated ion channels induce
children with minor head injuries require release of oxygen free radicals from the
neurosurgical intervention mitochondria
no single set of clinical criteria to detect all excessive production of oxygen free radicals
pediatric patients with radiographic lesions has causes lipid peroxidation of cell membranes,
been identified and liberal use of CT scanning oxidation of intracellular proteins and nucleic
may be advisable despite associated risks acids and activatioon of phospholipases A2 and C
risk for asymptomatic brain injury is higher in which hydrolyse membrane phospholipids
children under 6 months releasing arachidonic acid which generate free
age less than 2 years is an independent risk fatty acids, leukotrienes and thromboxane B2 all
factor for significant head injury of which are associated with neurodegeneration
and poor outcome after experimental traumatic
Age greater than 60 years is also an independent risk brain injury
factor for intracranial for intracranial injury TBI also increase intracellular potassium levels
leading to an imbalance of intracellular and
Mechanisms of Traumatic Brain Injury extracellular potassium, disruption of Na+/K+
General ATP ase cell membrane regulatory mechanism
trauma to the head causes primary injury such as and subsequent cell swelling
skull fracture, cerebral contusion, and severe TBI also causes a substantial decrease in
haemorrhage that is a direct consequence of the extracellular magnesium which impairs normal
traumatic incident glycolysis, cellular respiration and oxidative
secondary injury occurs hours or days after the phosphorylation contributing to brain injury
injury and may be the major determinant of the
patient's ultimate neurological outcome
7 Critical Care Trauma

Systemic Intracranial Subdural haematoma


Hypoxia Seizure seen in 20-25% of all comatose victims of
Hypotension Delayed haematoma traumatic brain injury
Hypocapnia Subarachnoid hemorrhage develop between the surface of the brain and
Hypercapnia Vasospasm the inner surface of the dura and are believed to
Hyperthermia Hydrocephalus result from the tearing of the bridging veins over
Hypoglycemia Neuroinfection the cortical surface or from disruption of major
Hyperglycemia venous sinuses or their tributaries
Hyponatremia typically spread over most of the cerebral
Hypernatremia convexity with the dural reflections of the falx
Hyperosmolality cerebri preventing expansion to the contralateral
Infection hemisphere
swelling of the cerebral hemisphere is common
Epidemiology due to damage to the underlying brain tissue;
traumatic brain injury is the leading cause for cerebral contusions are found in 2/3
morbidity and mortality among people aged 1 to classified as acute, subacute and chronic with
45 years each having a characteristic CT appearance
motor vehicle crashes are the major causes of acute subdural appears white, subacute lesions
head injuries among those aged 5 to 64 years old are isodense and chronic lesions are hypodense
while falls are the major cause among over 65s
males have twice the risk of traumatic brain Epidural haematoma
injury across all age groups develop between the inner table of the skull and
the dura, usually when the middle meningeal
Skull fracture artery or one its branches is torn by a skull
results from a contact force to the head that is fracture
usually severe enough to cause a brief loss of occur in 8-10% of those rendered comatose by
consciousness traumatic brain injury
linear fractures are the most common and the majority are located in the temporal or
typically occur over the lateral convexities of the parietal regions but they can also occur over the
skull (most often they are non-displaced) frontal and occipital lobes and rarely in the
a depressed skull fracture usually results from a posterior fossa
blunt force from an object with a small surface unlike the subdural haematomas their spread is
area such as a hammer limited by suture lines of the skull where the
the base of the skull can be fractured by severe dura is very adherent
blunt trauma to the forehead or the occiput an epidural space does not usually exist so the
clot must strup the dura from the inner table of
Examples of injuries associated with skull fracture: the skull as it enlarges resulting in the classic
i. anterior skull base fractures most often involve lenticular shape
the cribriform plate disrupting the olfactory epidural haematomas are uncommon in the
nerves infants and toddlers presumably because their
ii. posterior skull base fractures may extend skulls are more deformable and less likely to
through the petrous bone and internal auditory fracture and in patients older than 60 because
canal thereby damaging the acoustic and facial the dura is extremely adherent to the skull
nerves the classically described lucid interval after
iii. fractures of the squamous temporal bone are initial period of loss of consciousness followed by
frequently accompanied by a tear in the middle coma occurs in fewer than a third of patients
meningeal artery causing an extradural with most either remaining comatose or
haematoma remaining conscious after the initial injury
iv. depressed skull fractures are often accompanied
by cerebral contusion Intraparenchymal haematomas
v. dura is often disrupted with basilar skull fracture a haemorrhage within the brain substance that
resulting in CSF leak from the nose or ear which occurs after a very severe TBI and is usually
may allow bacteria to enter the intracranial associated with contusions of the surrounding
space tissue
8 Critical Care Trauma

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

penetrating injuries: alternatives to ventriculostomy include devices


high velocity projectiles such as bullets that contain a pressure (eg Codmans)
generally cause massive destruction of Advantages are:
brain tissue, severe brain swelling and i. they provide relatively accurate
often death measurements of global ICP
low velocity missiles such as knives or ii. they are easier to insert than EVDs
arrives do not cause the massive brain iii. they may cause fewer complications
injury associated with bullet wounds than EVDs
and usually only the tissue in the disadvantages of these systems are that they can
immediate path of the missile is only be calibrated at insertion and measurement
damaged drift may be significant over the course of a few
dural closure is important in these days
patients because it reduces the risk of
CSF leak and infection Surgical Treatment
prophylactic antibiotics should be i. evacuation of mass lesions
administered because the missile the first response to a rise in ICP should be
usually carries skin and hair into the to repeat a CT brain to exclude a new or
brain worsening mass lesion that might be
amenable to surgical intervention
Physiological Monitoring ii. decompressive craniectomy
General: evidence surrounding decompressive
i. continual end tidal CO2 and frequent analyses of craniectomy is contradictory
ABGs allow early detection of deteriorating while one study of patients with severe TBI
ventilatory status demonstrated that 6 month outcomes
ii. oxygen saturation should be continuously were similar among patient given large
monitored with pulse oximetry decompressive craniectomies than among
iii. blood pressure should be invasively monitored patients that did no despite lower GCS and
iv. CVP monitoring is often required and PACs are more severe radiological abnormalities in
required in rare circumstances the craniectomy group another study has
v. urine output is continuously monitored via an found that it did not improve ICP, CPP or
indwelling catheter mortality rates
another study suggested that for young
ICP Monitoring patients decompressive temporal
continuous ICP monitoring should be mandatory lobectomy improves outcome
for all patient with severe TBI and abnormal CT
findings because intracranial hypertension Medical Treatment
develops 53-63% of such patients. Monitoring of i. avoidance of hypoxaemia
ICP and MAP allows calculation of CPP which FiO2 should be titrated maintain normal
may be a more important value than MAP or ICP oxygen saturation
the gold standard for ICP monitoring is a high levels of PEEP may increase ICP;
ventricular catheter which has a number of however, clinical studies have shown that
potential advantages over alternative systems: the use of PEEP of up to 15cmH2O in
i. ventricular pressure is considered patients with ARDS does not increase ICP
more effective of global ICP than ii. maintenance of normocarbia
subdural, extradural or subarachnoid maintaining an arterial PCO2 of
pressure approximately 35 is advised to avoid
ii. subdural, extradural or subarachnoid cerebral vasoconstriction associated with
catheters are more prone to occlusion aggressive hyperventilation
iii. ventriculostomies can be rezeroed iii. avoidance of hypotension and hypovolaemia
after insertion hypotension should be aggressively treated
iv. ventriculostomies allow drainage of with normovolaemia achieved by infusing
CSF to treat intracranial hypertension normal saline (human albumin is
the overall complication rate of EVDs is 7.7% associated with increased morbidity and
with infection occurring in 6.3% and mortality in severe TBI)
haemorrhage occurring in 1.4% (some studies hypotension which is refractory to volume
indicate that infection rate increases markedly replacement should be treated with
after catheters have been in situ for five days) vasopressors or inotropes
11 Critical Care Trauma

anaemia should be treated; however, the viii. osmotherapies


precise level at which transfusion should a. MANNITOL
occur is not clear intermittent boluses of mannitol (0.25-
iv. maintenance of CPP 1g/kg every 3-4 hours as needed)
some advocate use of induced lowers ICP and increases CBF by
hypertension to maintain a CPP above expanding intravascular volume and
70mmHg; however a randomised trial of reducing blood viscosity within a few
patients with TBI comparing a group whose minutes of administration; its duration
CPP was kept above 70mmHg to a group of action is 3-5 hours
whose CPP was allowed to drift to 60 continuous infusion of mannitol is less
mmHg showed no difference in outcome at desirable than boluses because the
six months between the two groups and latter is less likely to lead to
more use of vasopressors and a higher extravasation of drug into the brain
incidence of ARDs in the group whose CPP causing a reverse osmotic gradient and
was maintained above 70mmHg increased oedema
others have found that brain tissue PO2 in the serum osmolarity and sodium level
patients with TBI does not fall until the CPP should be monitored frequently during
drops below 60mmHg mannitol adminisrtation to minimise
based on the above findings the current the risk of renal failure from ATN; the
recommendation is to maintain a CPP drug should be discontinued if the
above 60mmHg serum sodium exceeds 160mmol/L or
v. avoidance of intracranial hypertension the osmolarity exceeds 320mOsm
intracranial hypertension is defined as a b. HYPERTONIC SALINE
sustained ICP greater than 20mmHg 3% saline can be administered as an
several clinical studies have found that osmotherapy and titrated to serum
persistent intracranial hypertension is sodium
associated with significantly worse principle advantages of hypertonic
morbidity and mortality saline in this setting are:
based on the association with worse a. rapid effect which peaks in 10
outcome and the premise that intracranial minutes and wanes after 1 hour
hypertension can compromise cerebral b. end point for therapy is serum
perfusion and induce ischaemia, the sodium which is 145-155 and easily
aggressive treatment of intracranial monitored through ABGs
hypertension is almost universally c. there is less potential for
endorsed hypovolaemia than with mannitol
always consider physiological causes of d. there may be a better effect of CBF
raised ICP including seizures, fever, jugular for a given reduction in ICP
outflow obstruction and agitation e. HS is expensive
vi. sedation f. there is theoretical benefit in
increasing sedation may lead to rapid modulating the inflammatory
control on intracranial hypertension response
particularly in a patient who is posturing or principle disadvantages of hypertonic
agitated saline in this setting are:
the major disadvantages of sedation are a. need for central access
that the ability to determine an accurate b. hypokalaemia and hyperchloraemic
GCS is lost and sedative agents often acidosis
induce hypotension c. lack of outcome data
vii. venting of CSF d. increase in circulating volume and
in a patient with an external ventricular risk of CCF
drain intermittent or continuous venting of e. coagulopathy - HS may affect APTT
CSF is useful and INR as well as platelet
intermittent venting has the advantage of aggregation
allowing reliable measurement of ICP f. rapid changes in serum sodium
concentrations may result in
seizures and encephalopathy
12 Critical Care Trauma

g. some suggest that HS affects seizures may not be evident in patients


normal brain more than injured who are paralysed therefore seizure
brain which theoretically worsens prophylaxis should be continued in these
herniation patients and continuous EEG monitoring
ix. hyperventilation should be considered
the use of hyperventilation to lower ICP is xiv. DVT prophylaxis
controversial because its association with patients with TBI, particularly those who
cerebral vasoconstriction and potential are comatose or have associated injuries
worsening of brain ischemia such as pelvic or long bone fractures are at
recent evidence suggests that even brief high risk of thromboembolic events
periods of hyperventilation may worsen patients should receive early prophylaxis
secondary brain injury by causing an including the use of sequential calf
increase in extracellular lactate and compression devices
glutamate levels early use of both heparin and enoxaparin
its only role is probably in the patient in (within 2 to 3 days of injury) has been
whom other therapies have failed in whom demonstrated to be safe in clinical trials
emergent surgery is planned to control ICP and has not been demonstrated to cause
x. paralysis and cooling or worsen intracranial haemorrhage after
paralysis may help control ICP where other TBI
measures have failed; however, it is xv. nutrition
associated with an increased risk of malnutrition is common after TBI with
pneumonia and critical care neuropathies metabolic expenditure increasing
therapeutic hypothermia to 32-34 degrees significantly; early enteral nutrition should
has been studied in the 1st 24-48 hours be instituted
after TBI. While it has not been
convincingly demonstrated to improve Rehabilitation
outcome, it does consistently reduce ICP. rehabilitation of TBI patients begin in the ICU
In patients who are cool at arrival to within the first few days of injury with passive
hospital it appears to confer benefit in range of movement exercise and mobilisation to
subgroup analyses prevent deep vein thrombosis
xi. barbiturate coma
barbiturates are thought to be effective Prognosis after Traumatic Brain Injury
through their ability to reduce cerebral General
metabolic rate and blood flow predicting outcome after TBI can help guide
the major disadvantages with their use is acute and chronic care and help prepare the
the risk of hypotension and the fact they family for a typically protracted recovery process
preclude clinical brain death testing equally important is that further treatment may
xii. avoidance of hyperthermia be deemed futile and expensive critical care and
there is a log increase in neuronal death in surgery can thus be reserved for patients who
ischaemic brain regions for every degree will benefit
above 39 for at least 24 hours after brain
injury; aggressive treatment of sources of Predictors
fever should be pursued and fever should several clinical and radiological characteristics
be treated. Whether aggressive cooling and have proved useful for outcome prediction but
paralysis to achieve normothermia is they must be used in concert. These criteria are
warranted is unknown more useful for predicting death or vegetative
xiii. seizure prophylaxis state than for accurately predicting mild or no
contusions and subdural haematomas are dysfunction
well known to cause generalised seizures the most powerful outcome predictors are:
and anticonvulsant prophylaxis is therefore a) age
recommended for patients with these b) initial GCS score
lesions (usually phenytoin is given) c) pupil size and reaction to light
a prospective randomised trial has found d) ICP
no benefit in continuing seizure prophylaxis e) nature and extent of intracranial
beyond 7 days injuries
13 Critical Care Trauma

Age mortality increases from 17-65% if an extradural


old age correlates most consistently with a poor haematoma is not evacuated within 2 hours
outcome after traumatic brain injury after the onset of coma
traumatic coma data bank study or >700 patients
with severe TBI showed that among patients Traumatic subarachnoid
older than 60 years the incidence of death, the presence of traumatic subarachnoid
persistent vegetative state or severe disability haemorrhage is associated with a greater than
was 92%, 86% for those older than 56 and 50% 50% risk of death; however, many believe that
for younger patients this condition is merely a marker of more severe
older patients are more likely to have traumatic brain injury and has no direct association with
intracranial mass lesions and the presence of outcome
these insults strongly correlates with poor CT Findings
outcome
subsequent studies have demonstrated the low
probability of a good recovery for patients older
than 60 whose initial GCS is <8

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

Blunt Cardiac Injury Septal Injury


General septal injuries are found in 5-7% of patients
blunt cardiac injury ranges from asymptomatic dying from blunt trauma
patients with minor enzyme rises to patients ventricular septal ruptures are common than
with fulminant cardiac failure atrial ones and may manifest as a loud
occurs most commonly in motor vehicle holosystolic murmur or AV conduction
accidents but can occur following virtually any abnormalities
trauma to the chest
Coronary Artery Injury
Chest injury Chest related Odds ratio direct injuries to the coronary arteries are rare
death but lead to important sequelae of dissection and
Three fractured 17.3% 1.01 thrombosis
ribs unilateral LAD is the most susceptible (76%) followed by
Three fractured 40.9% 3.43 right coronary (12%)
ribs bilaterally cardiac catheterisation is the investigation of
Lung contusion 25.2% 1.82 choice and angioplasty may be performed
unilateral coronary artery laceration may result in
Contusion 53.5% 5.1 pericardial tamponade and myocardial
bilateral and ischaemia; the decision as to whether to ligate or
haemothorax reconstruct vessels can be complex and depends
on anatomy and associated injuries
Cardiac Rupture
80-90% are lethal within minutes Penetrating Cardiac Injury
may result from direct impact force to the heart cardiac penetration is rapidly lethal in 90% of
or pressure transmitted via venous channels, gunshot wounds and up to 50% of stab wounds
deceleration with laceration at junctions the most important factor for survival is rapid
between fixed and mobile structures (eg transport to a trauma centre, early diagnosis and
atriocaval disruptions), myocardial contusion immediate treatment; patients arriving in
with subsequent necrosis and rupture; broken extremes after penetrating chest trauma should
ribs or sternum penetrating the heart undergo ED thoracotomy
patients who reach the hospital alive typically gunshot wounds generally bleed freely into the
have a pericardial effusion and may develop chest while stab wounds are more commonly
pericardial tamponade associated with tamponade

Pericardial Injury Pericardial Tamponade


may result from direct thoracic impact or from should be suspected in all patients sustaining
an acute increase in intraabdominal pressire penetrating injuries to the anterior chest wall
tears most commonly occur on the left acute tamponade of as little as 100ml of blood
paralleling the phrenic nerve (64%) within the pericardial sac can produce life
herniation of the heart through a large tear may threatening haemodynamic compromise
be associated with significant cardiac compensatory mechanisms can transiently
dysfunction stabilise the haemodynamic status and fluid
resuscitation may improve the vital signs;
Valvular Injury however, a high index of suspicion and early
lethal cardiac trauma involves the valves in diagnosis are key
approximately 5% of patients bedside echocardiography is extremely helpful
the most commonly injured valve is the aortic if pericardial tamponade is present patient
followed by the mitral, tricuspid and pulmonary should be immediately transported to the
aortic cusps may be lacerated or avulsed when a operating theatre; if there is a delay a
sudden increase in intrathoracic pressure leads pericardiocentesis or subxiphoid pericardial
to a concomitant rise in aortic pressure window should be performed
violent compression of the heart in early systole pericardiocentesis is successful in decompressing
may tear mitral leaflets but more commonly 80% of cases with most failures due to clotted
leads to papillary muscle rupture blood in the pericardium; if pericardiocentesis is
aortic and mitral valve injuries often lead to unsuccessful and the patient remains
acute heart failure hypotensive with SBP <70 then ED thoracotomy
should be performed
17 Critical Care Trauma

Great Vessel Injury ED Thoracotomy


Penetrating injuries Indications
patients with penetrating injuries to Accepted indications
extrapericardial thoracic great vessels usually 1. Penetrating thoracic injury
succumb in the field traumatic arrest with previously
approach to surgical treatment of patients with witnessed cardiac activity
penetrating injuries to great vessels can be unresponsive hypotension (BP <70
inferred from the location of wounds and the mmHg)
chest radiograph 2. Blunt thoracic injury
unresponsive hypotension (BP <70
Blunt injuries mmHg)
blunt thoracic great vessel injuries require rapid exsanguination from chest tube
tremendous force because the aortic arch (>1500 mls)
branch arteries are protected by strong
musculoskeletal tissues Relative indications
the most common site of injury is the aortic 1. Penetrating thoracic injury with previously
isthmus (just distal to the left subclavian at the witnessed cardiac activity
location of the ligamentum arteriosum) followed 2. Penetrating non-thoracic injury with previously
by the innominate artery witnessed cardiac activity
experience with intravascular stenting is growing 3. Blunt thoracic injuries with previously witnessed
but is still relatively limited cardiac activity
in the American Association of Trauma
multicentre study, widening of the mediastinum Contraindications
was present in 85% of cases; however, 7% of Blunt injuries
patients with a torn aorta had a normal chest x- blunt thoracic injuries with no witnessed cardiac
ray activity
Helical CT scan is now well accepted as a multiple blunt trauma
screening test and in a large series had a severe head injury
sensitivity of 100% when haematoma adjacent
to the thoracic aorta was considered a positive Rationale
test General
once aortic injury is diagnosed, SBP and HR overall survival is between 4 and 33%
should be rapidly controlled to reduce shear main determinants of survival are:
stress using a rapidly reversible beta blocking i. mechanism of injury
agent ii. location of injury
paralysis is a significant risk associated with iii. presence or absence of vital signs
aortic repair due to cross clamp and spinal artery
occlusion Mechanism of Injury
penetrating thoracic injury has greatest survival
Respiratory Support of the Chest Injured Patient (18-33%)
isolated stab wounds causing tamponade have
survival approaching 70%
blunt trauma has a lower survival (0-2.5%) but
there is a distinct survival rate for patients with
isolated thoracic trauma (particularly those who
are rapidly exsanguinating from a chest tube)

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

Presence of Vital signs Operative Technique


presence of cardiac activity or amount of time General
since loss of activity is consistently related to primary aims of emergency thoracotomy are
survival i. release of cardiac tamponade
ii. control of haemorrhage
Resuscitation iii. access for internal cardiac massage
General secondary manoeuvres include cross clamping
primary causes of traumatic arrest are hypoxia, the descending thoracic aorta
hypovolaemia, haemorrhage, tension
pneumothorax and cardiac tamponade General approach
hypoxic arrest responds rapidly to intubation and a supine anterolateral thoracotomy is accepted
ventilation approach
hypovolaemia, tension pneumothorax and a left sided approach is used in all patients with
cardiac tamponade all characterised by a lack of traumatic arrest or left sided injuries
venous return so that chest compressions are a right sided approach is used for patients with
ineffective; they may increase cardiac trauma right sided injuries who are hypotensive but not
ACLS algorithms do not apply to traumatic arrest arrested
inotropes and vasopressors cause myocardial
ischaemia Specific technique
i. clean skin
Management of traumatic arrest ii. make a skin incision from the border of the
1. Hypoxia sternum to the mid-axillary line and continue
intubation and ventilation should this down to intercostals
rapidly reverse hypoxic arrest iii. incise intercostals with heavy scissors and blunt
2. Tension pneumothorax dissection
tension pneumothoraces should be iv. insert rib spreaders between the ribs and open
presumed and bilateral thoracostomies v. repeat on the other side if required
should be performed in traumatic vi. divide sternum with trauma shears and open
arrest chest at midline if required
3. Massive hemorrhage NB: once BP is restored internal mammaries with
treatment is control of haemorrhage need to be ligated
not fluids (fluid therapy prior to
haemorrhage control worsens Priorities
outcome in penetrating thoracic 1. relieve tamponade
trauma) anterior longitudinal incision then tear
4. Cardiac tamponade pericardium with fingers
needle pericardiocentesis may fail due 2. identify cardiac wound and appear
to blood being clotted close directly with non-absorbable3/0
FAST will indicate presence of sutures
pericardial fluid 3. identify pulmonary and hilar injuries
relieve massive lung or hilar bleeding
Fluid therapy with finger pressure
large volume fluid therapy should be avoided partial or intermittent occlusion may
prior to haemorrhage control; however, once be performed with tracheal tape to
haemorrhage is controlled patients will need avoid acute right heart failure
rapid correction of hypovolaemia to refill the 4. Identify aortic injuries
heart and restore perfusion to non-vital organ can be directly repaired with 3/0 non-
systems absorbable sutures
can be controlled with direct finger
Inotropes pressure
inotropes are contraindicated in hypovolaemia 5. consider aortic cross clamping
but may be required after control of ideally at level of diaphragm to limit
haemorrhage and cardiac repair spinal cord ischaemia
direct myocardial injury, ischaemia, acute cardiac
dilatation, pulmonary hypertension and
mediator release due to global tissue hypoxia
can all lead to cardiogenic shock which may
require inotropes
19 Critical Care Trauma

Abdominal Trauma - Assessment key conditions identified are: serious


Definition head and spinal cord injury
abdominal trauma consists of blunt and key treatment is: definitive airway if
penetrating trauma indicated, emergency treatment of
raised ICP
Penetrating abdominal trauma 5. Exposure and control of immediate environment
most commonly injured organs with stab expose patient and prevent
wounds are small intestine, liver and colon hypothermia
only one third of abdominal stab wounds
penetrate the peritoneum and only 50% of these Other procedures
require surgical intervention several monitoring and diagnostic adjuncts occur
85% of abdominal wall gunshot wounds in concert with the primary survey
penetrate the peritoneum and 95% of these i. ECG and ventilatory monitoring and
require a surgical procedure for correction continuous pulse oximetry
ii. decompress stomach with NG or OG
Blunt abdominal trauma tube once airway is secured
spleen and liver are the most commonly injured iii. insert a foley catheter during
organs; small and large intestines are the next resuscitation phase (foley catheter
most commonly injured placement is contraindicated if
urethral injury is evident as identified
Initial Assessment by blood at the meatus, ecchymosis or
Primary survey scrotum or labium majora or high
1. Airway (ability of air to pass unobstructed to the riding prostate - retrograde
lungs) urethrogram is required for these
obstruction of the airway due to direct patients)
injury, oedema, foreign body or
inability to protect the airway because Resuscitation and Comprehensive Assessment
of depressed level of consciousness Resuscitation phase
Key treatment is establishment of continues throughout primary and secondary
airway survey and until treatments are complete
2. Breathing (ability to ventilate and oxygenate) fluids are required to sustain intravascular
key clinical findings are: absence of volume, tissue and organ perfusion and urine
spontaneous ventilation, absent of output
asymmetrical breath sounds, dyspnoea administer blood for hypovolaemia that is
hyperresonance, dullness, gross chest unresponsive to crystalloid boluses
wall instability or defects that end points are normal vital signs, absence of
compromise ventilation blood loss, adequate urine output and no
key conditions to identify are: evidence of end organ dysfunction; blood lactate
pneumothorax, endotracheal tube and base deficit on an ABG may be helpful in
malposition, tension pneumothorax, patients who are severely injured
haemothorax, sucking chest wounds,
flail chest Secondary survey of abdominal trauma
key treatment is: chest tube 1. Inspection
3. Circulation examine for the presence of external
key clinical findings are: collapsed or signs of injury noting patterns of
distended neck veins, signs of abrasion and/or ecchymotic areas
tamponade, external sites of lap belt bruising is positively correlated
haemorrhage with rupture of the small intestine and
key conditions identified are: increased incidence of other
hypovolaemia, cardiac tamponade, intraabdominal injury (20-30% of
external haemorrhage patients with lap-belt marks have
key treatment is: IV access, fluid associated mesenteric or intestinal
resuscitation, compression of sites of injuries)
bleeding bradycardia may indicate free
4. Disability intraperitoneal blood
key clinical findings are: decreased Cullen sign (periumbilical ecchymosis)
level of consciousness, pupillary may indicate retroperitoneal
asymmetry, gross weakness
20 Critical Care Trauma

haemorrhage; however, this usually involves performing a minilaparotomy with


takes hours to develop placement of a lavage catheter into the
flank bruising and swelling may raise peritoneal cavity directed towards the pelvis
suspicion for retroperitoneal injury the return of gross blood is a positive result
inspect genitals and peritoneum if DPL is grossly negative the 1L of warmed saline
2. Palpation is instilled into the abdominal cavity and then
fullness may indicate haemorrhage drained back into the intravenous fluid bag by
crepitation of lower rib cage may gravity. The effluent lavage is sent to the
indicate hepatic or splenic injury laboratory for analysis.
rectal and vaginal examination identify laboratory criteria for a positive DPL in blunt
potential bleeding and injury trauma are:
signs of peritonitis soon after injury i. >100000 rbcS/mm3
suggest leakage of intestinal contents; ii. >500 WBC/mm3
peritonitis due to intra-abdominal iii. presence of food particles
haemorrhage may take several hours iv. presence of bile
to develop v. presence of bacteria
ongoing haemorrhage is the most likely cause of problems with DPL:
persistent or recurrent haemodynamic instability i. an invasive procedure
initial goal is not to diagnosis specific abdominal ii. 1/4 of patients with a positive DPL will
organ injury but rather to determine whether have a non-therapeutic laparotomy
there are signs and symptoms that indicate a iii. 5% false negative rate with
need for immediate laparotomy retroperitoneal, hollow viscus or
diaphragm injuries
Imaging and Laboratory Studies
Trauma series CT abdo/pelvis
CXR identifies haemothorax, pneumothorax and is the diagnostic modality of choice for
pulmonary contusion haemodynamically stable patients
AP pelvis can confirm presence of significant the major reason not to obtain a CT scan is
pelvic fracture haemodynamic instability
lateral c-spine can identify non-survivable neck allows haemoperitoneum and its source to be
injury identified and allows specific injuries to be
graded
FAST CT also permits evaluation of retroperitoneal
used to identify free fluid in the peritoneal cavity structures including the kidneys, major blood
FAST has a sensitivity of 70-95% vessels and bony pelvis
involves directing to ultrasound probe in four the majority of blunt solid organ injuries are now
regions managed non-operatively in trauma centres;
i. the subxiphoid location to determine however a blush of intravenous contrast agent
whether there is fluid in the pericardial indicates active extravasation from a bleeding
space and to make a rough assessment vessel and is strong predictor of failure of non-
of contractility and filling state operative management
ii. the right upper quadrant problems with CT scanning are:
iii. the splenorenal recess i. the need to transfer the patient to
iv. the pelvis radiology
problems with FAST ii. the time associated with transfer and
i. operator dependent scanning
ii. false negative rate in children is high iii. risks associated with intravenous
iii. technically more difficult with obesity contrast agents
and sc emphysema iv. the fact hollow viscus, diaphragmatic
and pancreatic injuries are frequently
DPL missed on initial scanning
has an accuracy of 98% for detection of 30% of patients with lumbar Chance fracture
haemoperitoneum but does not determine have associated bowel or mesenteric injuries
source
generally performed in patients too unstable for
CT
21 Critical Care Trauma

Criteria for Positive DPL Rewarming


warm blankets and a warm room are essential
and should be prepared before the patient
arrives
all intravenous fluids should be warmed
rarely invasive techniques for active rewarming
may be required

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

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