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Basic trauma critical care
Indications for ICU admission
Requirment for:
- airway protection and mechanical ventilation
- cardiovascular resuscitation
- severe head injury
- organ support
- correct coagulopathy
- invasive monitoring
- active rewarming of hypothermic patients
Aims
- physiologic optimization
- anatomical optimization
- identify all injuries
- prevent complications
ICU assessment
When the patient arrives in the ICU repeat the primary and secondary surveys.
Repeat primary survey
Airway
- ETT secure and appropriately positioned
Breathing
- ventilation of both sides of chest
- appropriate mode if ventilation
- adequate minute ventilation
- arterial blood gases
- adequate FIO2 to maintain SaO2>94%
Circulation and control of haemorrhage
- adequate IV access
- appropriate monitoring
- urine output
- blood pressure
- central venous pressure
Disability
- GCS
- limb movements
- appropriate sedation
Environment
Repeat secondary survey
Repeat secondary survey and review investigations looking for missed
injuries, in particular:
- spinal injuries
- traumatic aortic rupture
- myocardial contusion
- suspicion based on mechanism
- unlikely if admission ECG completely normal
- if ECG not normal perform echocardiography
- diaphragmatic rupture
- abdominal compartment syndrome
Take past medical history and drug history
Preventing complications
- early definitive surgery
- including early fracture fixation for stable patients
- reduces ARDS, fat embolism and mortality
- "window of opportunity" before patient develops other
complications
- easier nursing
- early mobility
- early enteral feeding
- prevent infection. (Note that patients may develop distributive shock due
to a marked systemic inflammatory response to trauma and that the presence
of distributive shock is not necessarily an indication of infection).
- early extubation
- remove "dirty" cannulae
- remove non-vital tubes
- head up position in enterally fed patients
- selective gut decontamination
- prevent hypothermia. Hypothermia associated with:
- increased mortality
- decreased cardiac output
- coagulopathy
- increased metabolic demand due to shivering
- immunosuppression
- prevention of thromboembolism
- methods used depend on risk of thromboembolism and other injuries.
Increased risk associated with requirement for blood transfusion, spinal
cord injury, lower limb and pelvic fractures. Treatment options include:
- compression stockings
- sequential compression devices
- low molecular weight heparin
- unfractionated heparin
- prophylactic IVC filter
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