Trauma and Critical Care

General Trauma Care

TEG

• • Management of thromboelastogram results:

    • R= coags, need FFP if long (1st step)

    • R >10 = FFP

    • TEG-ACT > 140 = FFP

    • Angle= fibrinogen, if low give cryo / FFP

    • K-time > 3= cryo

    • alpha angle < 53= cryo

    • MA= platelet/fibrin, need platelet if low (2nd step)

    • MA < 50 = plt

    • CRT MA reflects platelets and fibrinogen

    • CFF MA reflects just fibrinogen

    • Ly30= fibrinolysis

    • LY30 > 3% = TXA

    • CKH gives effect of heparin (If CK R is high and CKH R is normal, it means reversing heparin would normalize CK R time)

  • http://www.surgicalcriticalcare.net/Guidelines/TEG%202014.pdf

TEG does not account for ASA or Plavix, must use platelet mapping:

• ADP inhibition >60% = give platelets or ddavp. 

  • • Plt MAP HKH MA gives overall clot strength (hypocoagulable if low)

    • Plt MAP ACTF MA gives fibrinogen input (give fibrinogen if low)

    • Plt MAP ADP MA gives platelet function due to ADP inhibitor (ex Plavix) (give plt if low)

    • Plt MAP arachadonic acid (aa) MA gives platelet function due to ASA 

• TEG does not account for:

  • hypothermia

  • hypocalcemia

  • vWF deficiency

  • platelet inhibition (unless using platelet mapping)

• TEG directed blood product administration

 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

• • Management of anticoagulants.

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.

  • Maintain plateau Pressure (Pplat)< 30cmH2O

  • ARDSnet ventilation protocol.

  • ARDS net predicted body weight and tidal volume. 

Acid Base Disorder

• • Calculating expected pH based on pCO2

    • acute change in pH= 0.008 x (pCO2-40)    or    pH increases 0.08 for every 10mmHg decrease pCO2 (below 40)

    • chronic change in pH= 0.003 x (pCO2-40)    or    pH increase 0.03 for every 10mmHg decrease pCO2

  • Calculating expected HCO3 based on pCO2: helps determine if there is a mixed acid/base or appropriate compensation

    • acute resp acidosis HCO3 increase by 1mEq/L for every 10mmHg increase pCO2

    • chronic resp acidosis HCO3 increase by 3-4mEq/L for every 10mmHg increase pCO2

    • acute resp alkalosis HCO3 decrease by 2mEq/L for every 10mmHg decrease pCO2

    • chronic resp alkalosis HCO3 decrease by 5mEq/L for every 10mmHg decrease pCO2

  • Delta Ratio= (AG - 12) / (24 - HCO3)

    • determines ratio of change in anion gap to change in bicarb

    • assesses if metabolic acidosis is mixed process

    • Results:

      • <0.4 = hyperchloremic nomal gap acidosis

      • <1 = high AG acidosis and normal AG acidosis

      • 1 to 2 = pure AG acidosis

        • lactic acidosis averages 1.6

        • DKA closer to 1

      • >2 = high AG acidosis and concurrent metabolic alkalosis OR chronic compensated respiratory acidosis

  • Winter's formula predicts pCO2 compensation in metabolic abnormality

    • linear relationship in metabolic acidosis

    • less useful in metabolic alkalosis, actual pCO2 > 50 suggests concomitant respiratory acidosis

  • Metabolic Alkalosis

    • chloride responsive = urine Cl < 25

      • Tx: NS, PPI, stop diuretics

    • chloride unresponsive = urine Cl >40

      • Tx: K+ replacement, spirinolactone (inhibit aldosterone), stop steroids, ace inhibitor, acetazolamide

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 (can treat if symptomatic). 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. If baseline cortisol < 9mcg/dl can treat emperically. 

    • 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

• Hormonal Resuscitation= for brain death or severe TBI. Consider for >15mcg vasopressor requirement. Monitor K+. 

• • Levothyroxine- 10mcg/hr

  • vasopression 1U boluse + 0.5-4U/hr (titrate to SVR 800-1200)

  • Methylprednisolone: 15mg/kg bolus

  • Insulin 1U/hr minimum (titrate to BG 120-180mg/dl)

Spinal Injury

• 3mo VTE prophylaxis for severe motor deficits

• scheduled I/O cath q6h, increase if >500ml UOP

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 pCO2 > 60

  • 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

• • AAST splenic laceration grading scale.

Liver injuries

• • AAST liver laceration grading scale.

Duodenal Injuries

• • AAST duoadenal laceration grading scale.

Pancreatic Injuries

• • AAST pancreatic lacerations grading scale.

Retroperitoneal injury

• • Zone 1= Central

    • penetrating --> open all

    • blunt --> open all

  • Zone 2= Lateral

    • penetrating --> open for expanding hematoma or active bleeding; explore retrocolic; explore ureter if in near wound. 

    • blunt --> open for expanding hematoma or active bleeding

  • Zone 3= Pelvic

    • penetrating --> open all

    • blunt --> do not open if pelvic fxr, intact pulses, no expansion; angioembolization is preferred to opening hematoma. 

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.

Lower Urogenital Trauma

• Evaluation of Hematuria with CT cystogram in:

  • Blunt trauma

    • pelvic ring fxr and > 30rbc/HPF or gross hematuria

    • gross hematuria with free fluid <25 Hounsfeild units

  • Penetrating trauma

    • any hematuria

• Evaluation of hematuria with retrograde urethrography in:

  • blood at meatus

  • high suspicion of urethral injury (wide pubic diastasis)

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

Orthopedic injury

• Upper extremity splints

• Lower extremity splints

Hand Exam

• https://www.nuemblog.com/blog/2018/4/9/hand-exam

  • Radial n

    • sensation: dorsal thumb, index, 1/2 middle

    • motor: wrist or thumb extension

  • Median n

    • sensation: palmar thumb, index, middle, 1/2 ring; dorsal tips of thumb, index, middle

    • motor: OK sign

  • Ulnar n

    • sensation: palmar or dorsal little and ring

    • motor: spread fingers against resistance, cross middle finger over index

Rattle Snake Bite

• • • Sx of envenemation:

• • 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

    • Intubate 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

• CRP

  • Minor elevation (3-10mg/L or 0.3-1mg/dl) = low grade inflammation

  • Marked elevation (100mg/L or 10mg/dl) = 80% infectious

• 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

• Cdiff treatment

  • 1st episode, WBC<15, Cr< 1.5 --> PO vanc 125QID x10d

  • 1st episode, WBC>15, Cr>1.5 --> PO vanc 125 qid x10d

  • fulminant (shock, toxic megacolon) --> PO vanc 500QID, or by rectum, IV flag 500q8, OR

• Postsplenectomy leukocytosis

  • platelet:wbc ratio < 20 and WBC >15 are concerning for infection.

  • https://pubmed.ncbi.nlm.nih.gov/16385282/

DVT Prophylaxis

• Injury specific DVT prophylaxis: 

  • Pelvis/Hip fxr = lovenox for 2 weeks post injury then ASA 81mg BID for 4 weeks

  • femur / tibia / knee = lovenox  or ASA 81mg BID for 2 weeks

  • Spinal cord injury = 8-12 weeks DVT prophylaxis

• Trauma lovenox dosing:

  • BMI < 35 = 30mg BID 

  • BMI > 35 (morbidly obese)= 40mg BID 

  • BMI < 18 or TBW < 45kg (low weight) = 30mg daily 

  • CrCl < 30 = 30mg daily

  • Dialysis = heparin

• Anti-Factor Xa dosing (from https://wyomingmedicalcenter.org/documents/WMC_Anticoagulation_Protocol.pdf)

  • Use peak levels, 4hrs after dose administration

  • prophylaxis target= 0.2-0.5 IU/ml

    • Dose adjustment:

      • <0.2 increase by 25%, recheck after 2nd, 3rd dose

      • 0.2-0.5 continue dose, recheck weekly

      • 0.51-0.69 decrease by 20%, recheck after 2nd, 3rd dose

      • 0.7-1 decrease by 30%, recheck after 2nd, 3rd dose

      • > 1 hold until Anti-Xa < 0.2, decrease 40%.

  • Treatment target= 0.6-1 IU/ml

    • Dose adjustment:

      • <0.35 - increase by 25%

      • 0.35-0.49 increase by 10%

      • 0.5-1 continue dose

      • 1.1-1.5 decrease by 20%, recheck before next dose

      • 1.6-2 hold for 3hrs and decrease by 30%, recheck before next dose and 4hr after next dose

      • >2 hold until antiXa < 0.5, decrease by 40%

• Timing and regimen for DVT prophylaxis from AAST. 

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. 

• Ketamine:

  • Analgesia 0.15mg/kg

    • 2.5ug/kg/min rib fxr continuous analgesia based on Trauma Journal

  • Recreational 0.2-0.5 mg/kg

    • 50mg is good sedative dose

  • RSI 1mg/kg

• Flumazenil- 0.2mg qmin for benzo overdose max 5 doses

• Naloxone- 0.4-2mg q2min for opioid overdose

• Coumadin reversal protocol

  • QT prolongation > 450ms (definitely > 500ms) risks sudden death, but no consensus on when to stop the med (amiodarone, seroquel, sotalol, haldol...) 

  • CT Contrast Allergy Rapid Prep

    • 1st) Hydrocortisone 100mg IV 30min prior to CT

    • 2nd) Hydrocortisone 100mg & Benedryl 50mg IV just prior to CT

  • Platelet transfusion triggers: 

    • < 100 for head trauma

    • < 50 for major surgery or massive transfusion

    • < 20 for LP

Hyponatremia

• Evaluate with Posm, Una, Uosm

• Una < 30mEq/L (=30mm/L) is 80% sensitive and 100% specific for saline responsive (hypovolemic)

• serum uric acid < 4mg/dl is 75% sensitive, 89% specific for SIADH

• Uosm < 100 is polydipsia

• High Posm Ddx: diuretics, adrenal insufficency, salt wasting

• Normal Posm Ddx: renal failure, alcohol, TURP, hyperglycemia

• Low Posm Ddx: SIADH

• SIADH= Posm < 275mOsm/kg, Una >40meq/L, Uosm > 100mOsm/kg

• Initial correction with HTS

• https://www.the-hospitalist.org/hospitalist/article/126121/how-should-hyponatremia-be-evaluated-and-managed