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Basic trauma crit care

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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

  • prevent hypothermia

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
 

©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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