Trauma and Critical Care

 
 

 

General Trauma Care

TEG

  • Management of thromboelastogram results:
    • R= coags, need FFP if long (1st step)
    • Angle= fibrinogen, if low give cryo / FFP
    • MA= platelet/fibrin, need platelet if low (2nd step)
    • Ly30= fibrinolysis
  • TEG does not account for ASA or Plavix.

ROTEM

  • Thromboelastogram result interpretation:
    • CTin = elevated with heparin or intrinsic coagulation defect
    • CTex= elevated with extrinsic coagulation defect
    • A10in,ex= lowered with weak clot (platelet, fibrinogen or factor XIII)
    • MCFin,ex= lowered with weak clot (platelet, fibrinogen or factor XIII)
    • MCFfib= lowered with poor fibrin
    • MLin,ex,fib > 15%= fibrinolysis
  • Endpoints for transfusion from ACS TQIP:
    • FFP for either
      • CT exTEM>100s or
      • CT inTEM>230s
    • cryo or FFP for MCF fibTEM<8mm
    • platelets for both:
      • MCF exTEM<45mm and 
      • MCF fibTEM>10mm
    • antifibrinolytic (TAA) for ML exTEM>15%

Anticoagulation

Ventilator Management

  • Rapid shallow breathing index (RSBI)= RR / Tv. Want < 105 for extubation; although <65 is ideal.
  • Negative inspiratory force (NIF)= want < -20 for extubation.
  • Tidal volume (Tv)= want 5ml/kg for extubation.
  • Vital capacity= want 15ml/kg for extubation.
  • ARDSnet ventilation protocol.

Hypotension Management

  • Adrenal Insufficency is treated with steroids emperically, but can do ACTH stimulation test.
    • Check cortisol level. If serum cortisol is < 20mcg/dl this suggests adrenal insufficency. Then, administer ACTH 250mcg IV push (time zero). Next, check serum cortisol at 30min and 60min. If the cortisol increase is < 9mcg/dl this is diagnostic for adrenal insufficency.
    • Dexamethasone does not interfere with ACTH stimulation test.
    • Prednisone 5mg = Cortisone 25mg = Dexamethasone 0.75mg = hydrocortisone 20mg
  • Postop Hypotension is from: MI, CHF, PE, bleeding, coagulopathy, sepsis, medication induced, malignant hyperthermia, blood transfusion reaction.
    • Workup: foley, cxr, ekg, cbc, cmp, pt/ptt/inr, Echo, cardiac enzymes.
      • Have blood available, good IV access, monitors, pulseox
      • Ask about drain output.
    • Management: fluid challange with 1L saline, give blood if suspect anemia. Manage cause.
      • MI suggested with elevated wedge, elevated PAP, EKG changes, elevated enzymes --> cardiology consult, B-blocker, ASA, morphine, O2, heparin of tolerate, cardiac cath, IABP
      • Fever --> malignant hyperthermia, transfusion rxn, adrenal insufficency
      • Transient responder or non-responder needs OR exploration for bleeding or sepsis (if not MI/CHF/PE)
     

CNS trauma

Head injuries

  • GCS score= glascow coma score. < 8 consider ICP monitoring. <13 consider intubation.
    • Eyes
      • 1= closed
      • 2= opens to pain
      • 3= opens to voice
      • 4= open
    • Verbal
      • 1= no sound
      • 2= makes sounds
      • 3= makes words
      • 4= disoriented
      • 5= oriented
    • Motor
      • 1= no movement
      • 2= decerebrate (extensor posturing)
      • 3= decorticate (flexor posturing)
      • 4= withdraws from pain
      • 5= localizes pain
      • 6= follows commands
  • Epidural hematoma= from injury to the middle meningeal artery. Can see pupil dilated on ipsilateral side. There is often a lucid interval. Can see contralateral posturing
  • Subdural hematoma= injury to bridging veins
  • Brainstem herniation= dilation of both pupils, must rule out pharmacologic effect
  • Pediatric head trauma=

    • Do not need head ct if: <2yr, GCS 15, no depressed skull fxr. (PECARN criteria). If >2yo can avoid if no worsening HA, vomiting, or LOC.
    • Consider CT or 6hr obs if: nonfrontal scalp hematoma, loc> 5 sec, not acting right, severe mechanism, <3mo, vomiting, worsening headache

Acute Management of TBI

  • Cerebral perfusion pressure is the most important for management of TBI.
    • want ICP < 20-25mmHg
    • want SBP > 100 mmHg
    • want MAP > 80mmHg before ICP monitor inserted
    • want PC02 35-45mmHg
    • want PaO2 > 100
    • want pH 7.35-7.45
    • want temp 36-38C
    • want Glucose 80-180 mg/dl
    • want serum sodium 135-145
    • want INR < 1.4
    • want Platelet > 75k
    • want Hb > 7
    • CPP = MAP - ICP
    • want CPP > 60 mmHg
  • Mannitol can acutely decrease ICP (30min) and increase blood volume (cerebral blood flow) given as 20% mannitol 0.25 to 1g/kg, then 0.25g/kg q4hrs
    • goal serum Osm 315-320 mOsm.
    • do not want serum osm > 320mOsm.
  • Hypertonic saline (3% NaCl) may be superior to mannitol as a 250ml Bolus, then 40ml/hr. 
    • goal CPP > 60-70 mmHg
    • goal ICP 20-25 mmHg
    • goal PaCO2 30-35 mmHg
    • serum osm 315-320 mOsm.
    • serum Na 145-155 mmol/L
  • Drain ventriculostomy up to 10-20ml/hr
  • Additional military protocols are available.
  • Diabetes insipidus is the decreased secretion of ADH (central) or resistance to ADH (nephrogenic). Central DI can be seen in TBI.
    • Dx with urine specific gravity of < 1.005, urine osm < 200mOsm/kg, plasma osm > 287 mOsm/kg, and > 3L urine per day.
    • Tx goal is to reduce serum sodium 0.5mmol per hour.
      • hypo-osmolar fluid replacement orally or IV
      • ddAVP 1-2 mcg IV BID

Spinal Injury

Death

  • Brain Death
    • Family must be notified
    • Exclusion: hypotension (BP >100), hypoxia hypoglycemia, Extreme I/o imbalances, locked in state (no paralytics, cannot move eyes to command), cspine/facial trauma, hypothermia (<36), intoxications, metabolic abnormalities
    • Must show irriversible:
      • GCS 3
      • Areflexia (but ensure DTR present and not paralized)--> pupils 3-8mm and fixed, no ocular movements (oculocaloric or oculocephalic), no corneal, no cough
      • Apnea Test, repeat after ~6hrs
    • Apnea test:
      • Baseline ABG PCO2 40+5
      • Oxygenate to PO2 200
      • Temp >36deg
      • Keep SBP >90mmHg
      • Disconnect vent and uncover patient
      • Provide 100% O2 (red rubber to level of carina)
      • Observe respiratory movements
      • ABG 7-10min to see if CO2 increases by 20 or pH < 7.24
    • Confirmatory test: not required but used if missing 1-2 parts of prior requirements or indeterminate apnea test. Especially with CO2 retainer, CHF, hemodynamic instability, severe obesity.
      • cerebral angiogram
      • EEG
      • Brain scan (doesn't image posterior circulation
      • Transcranial doppler
  • Cardiopulmonary death:
    • Warm >90 degF 
    • Brief neuro exam: GCS3, pupillary reflex, corneal reflex
    • Cardiac: 2min no pulse or 3min asystole (EKG, a-line)
    • Plum: 2min no breathing

 

Neck trauma

Zones of the neck

  • Zone 1= clavicals to the cricoids cartilage (inferior trachea, esophagus, brachiocephalic trunk, subclavian arteries, common carotids, thyrocervical trunk, thoraci duct, thyroid, spinal cord)
  • Zone 2= cricoid cartilage to the angle of the mandible (common carotids, internal/external carotids, IJ veins, larynx, hypopharynx, cranial nerves 10, 11, 12, spinal cord)
  • Zone 3= angle of the mandible to the base of the skull (carotids, vertebral arteries, IJ veins, pharynx, cranial nerves, spinal cord)
Exposure
  • Zone 1
    • left--> left anterior thoracotomy, can use left posterolateral thoracotomy to better expose arch, proximal left subclavian, left common carotid.
    • right--> sternotomy
    • proximal vertibral artery can be reached with transverse supraclavicular incision
  • Zone 2 --> parallel to SCM
  • Zone 3--> parallel to SCM, may require mandibular subluxation to reach distal ICA
  • Evaluation of esophagus/larynx --> barium swallow, intraoperative DL and esophagoscopy, intraoperative methylene blue into esophagus
Management
  • Esophagus
    • injury above arytenoids--> abx and NPO for 7d
    • below arytenoids--> 2 layer repair
    • unable to repair--> T-tube or spit exteriorization
  • Trachea
    • 2 layer repair
    • inner layer with vicryl to mucosa
    • outer layer with prolene to cartilage
    • keep intubated 3d
  • Larynx
    • tracheostomy

 

Thoracic trauma and Pulmonary Care

  • For pneumonectomy need FEV1 > 2L

  • For lobectomy need FEV1 > 1.5L

  • Ventilator Modes

    • APRV
      • Start with Phigh=28, Thigh=4s, Plow=0, Tlow=0.5s
      • to increase P02
        • increase Phigh by 2
        • decrease Tlow by 0.05 (to a Phigh=40 and Tlow=0.4)
        • increase Phigh by 2 (until Phigh = 50)
      • to decrease PCO2
        • increase Phigh by 2
        • increase Tlow by 0.05s (to a Phigh=40 and Tlow=0.9)
        • decrease Thigh (min 4)
      • More time or higher High pressure gives increased oxygenation
      • More time at Low pressure gives increased ventilation

Abdominal trauma

Splenic injuries

Liver injuries

Duodenal Injuries

Pancreatic Injuries

Retroperitoneal injury

  • Zone 1= Central
    • penetrating --> open all
    • blunt --> open all
  • Zone 2= Lateral
    • penetrating --> open unless 1) preop ct allows staging of renal parenchymal injury or 2) stable retrohepatic
    • blunt --> open unless preop CT shows the hematoma is around a reasonably intact kidney; do not open stable retrohepatic
  • Zone 3= Pelvic
    • penetrating --> open all
    • blunt --> do not open if pelvic fxr, intact pulses, no expansion

Smal bowel Injuries

Colorectal injuries

Urologic trauma

Renal vascular trauma

  • Venous avulsion - nephrectomy if have 2 kidneys; repair versus nephrectomy if have 1 kidney. Left renal vein can be ligated proximal to gonadal/adrenal; right renal vein ligation means nephrectomy
  • Arterial thrombosis - observe if have 2 kidneys; thrombectomy if have 1 kidney.
  • Arterial intimal injury - ovserve if have 2 kidneys with anticoagulation; repair or stent if have 1 kidney.
  • Arterial avulsion - nephrectomy.

Ureter injuries

Bladder injuries

Vascular and Extremity trauma

Vascular injury
  • Veins that should be repaired:
    • Popliteal vein- 50% risk of edema if ligated,  may need fasciotomy; high risk of limb ischemia with concomitant popliteal artery injury
    • Femoral/iliac veins are ok to ligate, use leg wraps. 
  • Arteries that should be repaired:
    • Internal carotid artery- 10-20% stroke with ligation
    • External iliac artery
    • Common femoral artery
    • Superficial femoral artery
    • Superior mesenteric
    • Inferior mesenteric
  • Hard signs- go to OR
    • Arterial bleeding
    • Rapidly expanding hematoma
    • Thrill or bruit 
    • Arterial occlusion= pain, pallor poikilothermia, pulseless,  paresthesia, paralysis 
  • Soft signs- Angio, serial exam, duplex
    • History of bleeding
    • Hematoma
    • Proximity
    • Decreased distal unilateral pulse
    • Neuro deficit
    • Diminished duplex wave form
    • ABI < 0.9

Rattle Snake Bite

    • Sx of envenemation:
Category
Tissue effect
Systemic signs
Coagulopathy and bleeding
Minimal
Swelling, pain, and ecchymosis adjacent to the bite site
None
Normal coagulation parameters•; no bleeding
Moderate
Swelling, pain, and ecchymosis less than full extremity or less than 50 cm if bite on head, neck, or trunk
Present but not life-threatening (eg, nausea, vomiting, diarrhea, oral paresthesia, unusual tastes, tachycardia, tachypnea, mild hypotension [systolic BP >90 mmHg in an adult])
Abnormal coagulation parameters•; no bleeding or minor hematuria, gum bleeding, and/or epistaxis
Severe
Swelling, pain, ecchymosis involving more than the entire extremity; greater than 50 cm if bite on head, neck, or trunk; threatens the airway; OR signs of compartment syndrome
Present and life-threatening (eg, respiratory insufficiency, marked tachycardia for age with severe hypotension, obtundation, seizures)
Markedly abnormal coagulation parameters• with serious bleeding
  • Treatment: based on severity of bite, not species identification.
    • CroFab 4-6 vials over 30-60min for mild envenemation. Can repeat if sx's don't improve.
    • TetTox; abx only for signs of infection.
    • Observe for worsening sx's.
    • Coagulopathy --> treat with CroFab.
    • Rhabdomyolysis --> treat with fluid and electrolyte support.
    • Elevated compartment pressures --> CroFab and elevation; may need fasciotomy for true compartment syndrome. 

Compartment Syndrome

  • 30mmHg is recommended as a critical point for fasciotomy
  • Measuring compartment pressures: Technique
  • abdominal compartment syndrome suggested at > 25mmHg and diagnosed at >30mmHg. 

Burns

  • Burn Depth
    • Superficial partial-thickness burn- pink, moist, easily blanch, hair follicles and papillary dermis intact
    • Deep partial-thickness burns- extend into reticular dermis, dry, eschar, slow capillary refill
    • Full thickness- dark, dry, leathery, insensate
  • Burn management
    • >20% BSA 2nd degree needs burn resuscitation
    • Tetanus toxoid if not within 12mo
  • Inhalation injury= suspected with unconscious, enclosed room, blister/soot in hypopharynx (not singed nasal hairs), carbonaceous sputum
    • Get COHb, ABG, lactate, cxr
    • Incubate early
  • American burn association transfer
  • Hydroflouric acid- treat with topical, local, and arterial Ca gluconate; can get hypoCa, hypoMg, HyperK
  • Chemical burn- initial tx with water irrigation to pH7
  • Carbon monoxide (CO) toxicity
    • Sx: flu like, delirium, MI, sz cva
    • Dx: COHb serum levels >5% no smoker or >13% smoker, pulse Co-oximetry
    • Tx: O2, consider hyperbaric O2
  • Cyanide (CN) exposure
    • Sx: n/v, dizziness, htn, shock
    • Dx: lactate>8 in non smoke exposure or >10 in smoke exposure
    • Tx: hydroxycobalamine, sodium thiosulfate


Electrical injury

  • Dx: Start with ABC's, electrolytes, cardiac enzymes, UA/micro, urine myoglobin.
    • Check extremities for compartment syndrome
    • Opthalmologic exam in tertiary survey

Sepsis

  • Procalcitonin
    • < 0.5 ng/ml --> systemic infection not likely
    • 0.5-2 ng/ml --> systemic infection possible, reassess PCT in 6-24hrs
    • >2 ng/ml --> sepsis likely 
    • > 10n ng/ml --> almost exclusively due to sepsis
  • SIRS criteria > 2:
    • Temp > 38 or < 36 C; >100.4 or < 96.8F
    • HR > 90
    • RR > 20 or PaCO2 < 32mmHg
    • WBC > 12, < 4, or bands > 10% bands

Common dosing

  • Vecuronium- induction with 100mcg/kg x1 = 10mg; intermittent paralysis with 10-15mcg/kg q15min= 1mg
  • RSI: Induce with etomidate 0.5mg/kg ; Paralyze with succinylcholine 1mg/kg; Contraindicated with difficult ariway, arrest, obstruction. 
  • Flumazenil- 0.2mg qmin for benzo overdose max 5 doses
  • Naloxone- 0.4-2mg q2min for opioid overdose
  • Coumadin reversal protocol
  • Platelet transfusion triggers: 
    • < 100 for head trauma
    • < 50 for major surgery or massive transfusion
    • < 20 for LP