Transcript Chest Trauma

TRAUMA
Dr Abdollahi
Trauma and associated life-threatening injuries account
for 10% to 15% of all patients hospitalized. Rapid
transport of a trauma victim to a trauma center rather
than to the nearest hospital has resulted in improved
outcome for the victim.
A level I trauma center is characterized by the
immediate availability of medical and nursing personnel
(emergency medicine physician, trauma surgeon,
neurosurgeon, orthopedic surgeon, plastic surgeon,
anesthesiologist,critical care specialist, radiologist,
and nurses), as well as the facilities needed to treat
trauma patients (emergency room, operating rooms,
radiology suite, intensive care unit [ICU], central
laboratory, and blood bank).
INITIAL EVALUATION
On arrival at the hospital, the patient's airway,
breathing, circulation, and neurologic status
(Glasgow Coma Scale, computed tomography [CT],
magnetic resonance imaging) must be rapidly
evaluated with the advanced trauma life support
(ATLS) protocol. The first priority is establishment
of an airway and administration of oxygen.
Occasionally, the trauma victim's trachea has been
intubated by the paramedic before arrival at the
hospital.
Confirmation of tube placement as reflected by a
sustained end-tidal CO2 waveform needs to be
established and documented immediately on arrival
at the hospital.
Early tracheal intubation in selected patients has been
a major factor in decreasing mortality from trauma.
Nasotracheal intubation should not be attempted if there
is the possibility of a basal skull fracture. If airway
obstruction exists and tracheal intubation cannot be
accomplished, emergency cricothyrotomy or
tracheostomy is indicated.
All trauma victims are assumed to be at risk for
pulmonary aspiration of gastric contents .
Cervical Spine Injury
In patients with a possible cervical spine injury (present
in 1.5% to 3% of all major trauma victims), orotracheal
intubation should be attempted only with the patient's
head stabilized in a neutral position (a rigid collar
decreases flexion and extension to about 30% of
normal and rotation and lateral movement to about
50% of norma!).
CT is the best way to diagnose cervical spine injury,
although two thirds of all trauma victims have multiple
injuries that may interfere with the ability or safety of
performing routine CT.
Thoracic Trauma
Thoracic trauma may involve the lungs or
cardiovascular system, or both. An upright inspiratory
chest radiograph is preferred for visualization of a
pneumothorax (high index of suspicion if rib fractures
are present), although the more likely radiograph will
be an anteroposterior supine film.
Pneumothorax or hemothorax is treated with a tube
thoracostomy (tube placed in the fourth or fifth
interspace in the midaxillary line and directed
posteriorly and attached to suction). Intrathoracic
vascular injury is suggested by a widening
mediastinum, whereas lung contusion is predictable
when a flail chest is present.
Abdominal Trauma
Abdominal injuries after blunt trauma are most often
splenic rupture or laceration of the liver, with both
resulting in profound hemorrhage. Intra-abdominal
hemorrhage is diagnosed by diagnostic peritoneal
lavage (DPL), abdominal ultrasound, or CT.
Continued hematuria after placement of a bladder
catheter indicates a possible bladder injury and the
need for a cystogram or intravenous pyelogram.
Orthopedic Trauma
If suspicion of a pelvic fracture is entertained, the
patient should be placed in a pelvic binder and
transferred to interventional radiology for an
emergency angiogram and possible intravascular
embolization instead of rushing the patient to the
operating room.
Evaluation of the extremities includes palpation of distal
pulses and visual inspection for symmetry of the
extremities to detect evidence of bleeding, especially
in the thighs after femur fractures. Early
immobilization of fractures is indicated.
Management of Anesthesia
General anesthesia is necessary for most trauma
patients who require surgical intervention. A "trauma
operating room" should be designated and
appropriately equipped . There is no ideal anesthetic
drug or technique for a trauma patient.
If the patient's trachea has not already been intubated,
rapid-sequence induction of anesthesia is indicated.
In the presence of hypovolemia, etomidate (0.1 to 0.3
mg/kg IV) or ketamine (1.0 to 3.0 mg/kg IV) is often
selected for induction of anesthesia because these
drugs are usually able to maintain stable
hemodynamics. In patients with suspected or known
cervical spine injury, avoidance of excessive head
movement during direct laryngoscopy is necessary.
Frequently, the dose of anesthetic tolerated by the
patient is too small to prevent movement, thus
necessitating skeletal muscle paralysis with a
neuromuscular blocking drug. In this regard, some
patients may experience recall of intraoperative
events.
Hemodynamic stability results from control of surgical
bleeding and restoration of the patient's blood
volume. Arterial blood gases, pH, and hematocrit are
measured at frequent intervals during anesthesia and
surgery. On a less frequent basis, it may be useful to
analyze blood for electrolytes, glucose, and
coagulation factors.
Fluid Resuscitation
Hypotension plus cellular hypoxia as a result of massive
hemorrage is the resone for production of lactic acid .
Goal-directed fluid resuscitation should be initiated
immediately after the establishment of venous access
because it serves to improve poorly perfused organs,
including the liver and skeletal muscles.
Initially, administration of a crystalloid solution such as
lactated Ringer's or Plasma-Lyte solution restores
intravascular fluid volume to help maintain venous
return and cardiac output.
SELECTION OF INTRAVENOUS FLUIDS
There is no advantage in using colloid for initial
resuscitation. When hemorrhage is extreme, it will be
necessary to eventually administer blood products.
Dilutional thrombocytopenia may accompany the
massive blood transfusion necessary to reestablish
intravascular fluid volume, whereas disseminated
intravascular coagulation may accompany persistent
hypotension.
Rarely, transfusion-related acute lung injury (ALI) can
also occur in trauma victims receiving blood
transfusions. A fluid warmer device should be used
for all intravenous fluids to minimize the likelihood of
hypothermia. The ambient operating room
temperature should be kept warm. A massive
transfusion protocol should be established.
Invasive monitoring, including an intra-arterial and
central venous pressure catheter, is recommended
Transport from the Operating Room
Severely injured patients often require continued
postoperative support of major organ function in an
rcu, especially mechanical ventilation of the lungs.
Patients usually remain intubated, sedated, and
paralyzed during transport to the Icu. Appropriate and
necessary drugs and equipment should accompany
the patient to the Icu. A transport ventilator is
preferred if the patient's oxygenation or ventilation (or
both) needs to be continuously supported.
Head Injuries
Depressed
Linear
Stellate
Basilar
Skull
Fractures
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TRAUMATIC BRAIN (HEAD) INJURY
Traumatic brain injury (TBl) reflects an insult to the brain
from an external mechanical force (high-energy
acceleration or deceleration) that might cause a
temporary or permanent impairment of physical and
cognitive functions along with changes in mental
status. TBl resulting from head injury is the leading
cause of death in individuals younger than 45 years
and accounts for approximately 40% of all deaths
from acute injuries in the United States.
Recognition
The hallmark of closed head injury is loss of
consciousness.
CT should be performed early because it is the most
important diagnostic test (evidence of increased
intracranial pressure [ICP], types of hematoma, and
hemorrhage), and the level of consciousness should
be classified according to the Glasgow Coma Scale .
Patient age, imaging studies, pupillary response, mean
arterial pressure, and initial Glasgow Coma Scale
score have been used to predict the overall outcome
in TBI patients.
Head Trauma Assessment
Glasgow Scale
Eye Opening
Motor Response
Verbal Response
Head Trauma Assessment
Glasgow Scale--Eye Opening
4 = Spontaneous
3 = To voice
2 = To pain
1 = Absent
Head Trauma Assessment
Glasgow Scale--Verbal
5 = Oriented
4 = Confused
3 = Inappropriate words
2 = Moaning, Incomprehensible
1 = No response
Head Trauma Assessment
Glasgow Scale--Motor
6 = Obeys commands
5 = Localizes pain
4 = Withdraws from pain
3 = Decorticate (Flexion)
2 = Decerebrate (Extension)
1 = Flaccid
Hypotension, hyperthermia, hypoxia, and elevated ICP
are strong predictors of a poor outcome. Patients with a
Glasgow Coma Scale score of less than 8 by definition
have severe TBI, and the mortality rate is about 33% to
55%. In contrast, the mortality rate is lower (around
2.5%) in patients with mild to moderate TBI (Glasgow
Coma Scale score of 8 or greater).
CriticaL Care
Critical care of a head-injured patient is based on
recognition and treatment of hazardous increases in
ICP.Interventions designed to provide cerebral
protection and resuscitation have been successful in
patients who experience TBI. Invasive monitoring,
including intraarterial and central venous catheter, is
recommended. Fluid resuscitation to maintain
adequate hemodynamics is important.
Low-volume resuscitation with hypertonic solution
saline, dextran, or a hemoglobin-based oxygen
carrier may be favored over conventional crystalloid
therapy. Jugular venous oxygen saturation (Sjo2),
potentially representing cerebral tissue oxygenation,
may be used to guide therapy.
Administration of barbiturates is recommended when
ICP remains increased despite traditional therapy.
MANAGEMENTOF INTRACRANIAL
PRESSURE
A catheter placed through a burr hole in a cerebral
ventricle or a transducer placed on the surface of the
brain is used to monitor ICP. Normally, ICP is around
15 mm Hg. Cerebral perfusion pressure is the
difference between mean arterial pressure and ICP.
Patients with a Glasgow Coma Scale score less than
8 should probably have their ICP monitored in a
neurosurgery ICU.
An abrupt increase in ICP during continuous monitoring
is known as a plateau wave . Painful stimulation in an
otherwise unresponsive patient can initiate a plateau
wave. Hence, the liberal use of analgesics to avoid
pain is indicated even in unresponsive patients.
Efforts to minimize the secondary injury from hypoxia
or decreased cerebral perfusion will ultimately be the
main goal for the care ofTBI patients.
Head Trauma Assessment
Cerebral Perfusion Pressure =
Mean Arterial Pressure - Intracranial Pressure
CPP = MAP - ICP
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TREATMENT
Early tracheal intubation plus mechanical ventilation of
the patient's lungs to avoid arterial hypoxemia has been
shown to improve outcome in the presence of TBI.
Hyperventilation may be deleterious because of
cerebral vasoconstriction.
Methods to decrease ICP
1.
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3.
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5.
6.
Posture;
Administration of osmotic diuretics,
Hypertonic saline,
Barbiturates;
Institution of cerebrospinal fluid drainage;
Craniectomy, lobectomy, and craniotomy.
A frequent recommendation is to treat sustained
increases in ICP greater than 20 mm Hg. Treatment
may be indicated when ICP is less than 20 mm Hg if
the appearance of an occasional plateau wave
suggests low intracranial compliance.
POSTUR
Elevation of the head to about 30 degrees is useful in
the care of head-injured patients to encourage
venous outflow from the brain and thus lower ICP. It
should also be appreciated that extreme flexion or
rotation of the head can obstruct the jugular veins
and restrict venous outflow from the brain. Placement
of a central catheter via the subclavian or the internal
jugular vein should be guided by the ultrasonic
technique.
If central venous pressure monitoring is needed, the
patient's neck should be prepared and draped before
the patient is placed in the Trendelenburg position.
The procedure should be terminated if ICP increases
during placement.
Hyperventilation
In the past, deliberate hyperventilation of an adult
patient's lungs to a Paco2 between 25 and 30 mmHg
to decrease ICP has been recommended. It was
presumed that the beneficial effects of
hyperventilation of the lungs on ICP reflect decreased
cerebral blood flow and resulting decreases in
intracranial blood volume.
However, deliberate hyperventilation as a treatment to
lower ICP has been questioned because of data
showing an increase in mediators, lactate, and
glutamate, even with a short period of
hyperventilation.
.
Hyperventilation of a head-injured patient's lungs as a
technique to reduce ICP is recommended only
in the presence of a mass lesion and impending
herniation before definitive surgical intervention
Osmotic Diuretics
Administration of hyperosmotic drugs, such as mannitol
(0.25 to 1 g/kg IV over a period of 15 to 30 minutes),
decreases ICP by producing a transient increase in the
osmolarity of plasma, which acts to draw water from
tissues, including the brain.
However, if the blood-brain barrier is disrupted, mannitol
may pass into the brain and cause cerebral edema
by drawing water into the brain. The duration of the
hyperosmotic effect of mannitol is about 6 hours.
The brain eventually adapts to sustained increases in
plasma osmolarity such that chronic use of
hyperosmotic drugs is likely to become less effective.
The diuresis induced by mannitol may result in acute
hypovolemia and adverse electrolyte changes
(hypokalemia, hyponatremia), thus emphasizing the
need to replace intravascular fluid volume with
infusions of crystalloid and colloid solutions. A rule of
thumb is to replace urine output with an equivalent
volume of crystalloids, most often lactated Ringer's
solution.
Glucose and water solutions are not recommended
because they are rapidly distributed in total-body
water, including the brain. If the blood glucose
concentration decreases more rapidly than the brain
glucose concentration, the brain water becomes
relatively hyperosmolar, and water enters the
central nervous system and exaggerates the existing
cerebral edema.
Hypertonic Saline
Hypertonic saline decreases ICP, improves cerebral
perfusion pressure, and enhances hemodynamic
function in TBI patients. In addition to its osmotic
effect on edematous brain tissue, hypertonic saline
also has vasoregulatory, neurochemical, and
immunologic effects.
Nevertheless, there is no significant outcome difference
in patients who receive either 7.5% hypertonic solution
or 20% mannitol.
Corticosteroids
Corticosteroids such as dexamethasone or
methylprednisolone have been used to decrease ICP
for more than 30 years. The mechanism for the
beneficial effect of corticosteroids is not known, but it
may involve stabilization of capillary membranes or a
decrease in the production of cerebrospinal fluid, or
both.
Nevertheless, there is no reduction in mortality in
patients treated with methylprednisolone in the first 2
weeks after TBl, thus suggesting that steroids should
no longer be routinely administered to these
patients.
Decompression Craniectomy
Emergency decompression craniectomy is a surgical
procedure performed to resolve the elevated ICP and
prevent herniation after head insults, especially
severe TBI.
Barbiturates
Administration of barbiturates may be recommended
when ICP remains increased despite deliberate
controlled hyperventilation of the lungs and druginduced diuresis.
.
This recommendation is based on the predictable ability
of these drugs to decrease ICP, presumably by
decreasing cerebral blood volume secondary to
cerebral vasoconstriction and decreased cerebral
blood flow. The goal of barbiturate therapy is to
maintain ICP at less than 20 mm Hg without the
occurrence of plateau waves
Discontinuation of the barbiturate infusion can be
considered when ICP has remained in a normal
range for 48 hours.
Failure of barbiturates to decrease ICP is a grave
prognostic sign.
A hazard of barbiturate therapy to lower ICP is
hypotension, which can jeopardize the maintenance
of adequate cerebral perfusion pressure.
Such hypotension is particularly likely in the presence
of decreased intravascular fluid volume. Dopamine
or dobutamine may be necessary in the event of
barbiturate-induced hypotension secondary to
myocardial depression. Transthoracic
echocardiography can be useful for evaluating
cardiac function in head injured patients.
Blunt Cardiac Injury
CHEST INJURIES
Chest injuries are a significant cause of mortality in
injured patients and account for 20% of traumarelated deaths in the United States. Both blunt and
penetrating chest injuries are treated with similar
principles of management. The initial evaluation of
patients with chest injuries should emphasize the
presence of an adequate airway and ventilation.
Thoracic Trauma
Penetrating Chest Injuries
• Majority are stab
wounds or gunshot
wounds (GSW)
• Lower mortality rates-less likely to include
multiorgan injury
• 85% of penetrating
chest wounds can be
treated with tube
thoracostomy and
supportive measures
Penetrating Chest Injuries
• 25,000 deaths per year
in the U.S. due to
GSWs to the chest
Penetrating Chest Trauma
• Wounds that enter or exit
inferior to the nipple or
the posterior tip of scapula
may perforate the dome of
the diaphragm.
• Any penetrating wound
such as this should be
considered to have an
abdominal component
until proven otherwise.
Work-up of Penetrating Chest
Trauma
• Physical examination
– Look, Listen, Feel
– Contusions, diminished or
absent breath sounds, SQ
emphysema can readily be
found
• CXR- best, least expensive and
fastest initial evaluation
• Ultrasound-may soon replace
CXR as initial radiographic
study in chest trauma
• Angiography- to look for great
vessel injuries
• CT Scan: for better evaluation
of chest wall and parenchyma
• Transesophogeal
Echocardiography
Penetrating Chest Injuries
• Operative intervention
required for:
– Massive or persistent
bleeding
– Massive air leak
– Tracheobronchial
injuries
– Esophageal perforation
– Cardiac or great vessel
injuries
– Post-traumatic
empyema
Penetrating Chest Trauma
Wounds that enter or exit inferior to the nipple or the
posterior tip of scapula may perforate the dome or
the diaphragm.
Any penetrating wound such as this should be
considered to have an abdominal component until
proven otherwise.
Penetrating Chest Trauma:Indications
for Mechanical Ventilation
Intrapulmonary Foreign Bodies
• When left in lung:
– 20% developed into
chronic bronchitis
– 6% : lung abscess
– 10%:
bronchopleural
fistula
– 5%: Empyema
Pulmonary Parenchymal Laceration
Massive air leaks and hemorrhage require immediate
operation
High Velocity Missile Injuries
• Wounds due to high
velocity missiles that
travel > 25,000 ft/s are
being seen with everincreasing frequency
• Military and civilian
Operative Intervention for
Hemothorax
• As noted previously
• Hemothorax:
massive = initial
drainage more than
1,000 cc or
• Continuous
bleeding of 200
cc/hr for 2 hrs
Blunt Cardiac Injury
EKG (for any blunt chest injury, persistent tachycardia,
ST-T changes or ectopy)
Cardiac enzymes (CPK, CK-MB and Troponin I)
Echocardiography (TEE)
Categories of chest wall injuries
• Scapular fractures
– 3% of blunt trauma
cases
– 54% have pulmonary
contusions
– 11% have associated
ipsilateral subclavian,
axillary or brachial
artery injury
• Over 1/3 are missed on
initial evaluation
Categories of chest wall injuries
• Flail chest
– Fx of at least 4
consecutive ribs in 2 or
more places
– Incompetent segment
of chest wall large
enough to impair
respirations
– Paradoxic motion
hinders creation of the
expected ipsilateral
negative inspiratory
force
Categories of chest wall injuries
Flail chest
Combination of pulmonary contusion and flail
chest has a mortality of 42%
Pulmonary contusion with flail chest: 75% require
ventilation
Flail chest ALONE: 48% require ventilation tx
Aggressive respiratory txs and IS with pain control
Pulmonary Contusion
Increase in pulmonary vascular resistance and A-aO2
difference
Diagnosis:
Dyspnea
Tachypnea
Hemoptysis
Cyanosis
Hypotension
Pulmonary Contusion
Treatment
Oxygen to maintain PaO2 above 60 mmHg
Vigorous chest physiotherapy
Use colloids instead of crystalloids when rapid
volume replacement is needed
Place PA catheter when large or rapid volume
replacement is needed
Use of steroids and antibiotics are controversial
Intra-thoracic Trauma: Great
Vessel and Mediastinal Trauma
Aorta
Pulmonary vessels
Tracheobronchial lacerations
Esophageal lacerations
Intra-thoracic Trauma: Great
Vessel and Mediastinal Trauma—
Work-up
Plain CXR to identify thoracic aorta injuries
Look for air in the mediastinum
Persistent airleak should cue into:
Bronchopulmonary or tracheobronchial injury
Mediastinitis, tube feedings in chest tube or saliva in
chest tube should cue into:
Esophageal injury
Intra-thoracic Trauma: Great
Vessel and Mediastinal Trauma—
Work-up
Bronchoscopy
Esophagoscopy
CT
Serial CXR
Initial CXR of Concern
Indications for Angiography
Lateral deviation of the NGT in esophagus
Widened mediastinum (>8cm)
Loss of visualization of the aortic knob
Hematoma of the Left cervical pleura (pleural cap)
Depressed left main stem bronchus
Rt lateral deviation of the trachea
Indications for Angiography
• Widened mediastinum
(>8cm)
Indications for Angiography
• Forward displacement
of the trachea on the
lateral CXR
• Fx of the 1st or 2nd rib
• Massive chest trauma
w/ multiple rib fx
• Fx or dislocation of
the thoracic spine
• Major deceleration
injury
The chest radiograph is analyzed for the presence
of pneumothorax, hemothorax, pulmonary contusion,
deviation of the tracheobronchial tree, widening of the
mediastinum, and abnormal mediastinal shadows.
These findings determine the need for additional
diagnostic or therapeutic interventions.
Tension Pneumothorax
Tension pneumothorax is a relatively common cause of
respiratory distress in a patient with chest trauma.
Placement of a chest tube without waiting for a chest
radiograph is warranted in patients with penetrating
chest trauma who are in significant respiratory
distress or have systemic hypotension. Patients with
chest trauma may also have significant hemorrhage
that requires prompt administration of crystalloid
solutions and blood.
Urgent Thoracotomy
The need for urgent thoracotomy because of chest
trauma is rare. In fact, because lobectomy and
pneumonectomy are associated with high mortality in
trauma patients, treatment techniques have been
developed that emphasize rapid and minimal lung
resection.
Guidelines for the need for emergency thoracotomy
include an initial blood loss of 1500 mL on placement
of the chest tube and continued bleeding of 200 to
300 mL/hr. Additional indications for thoracotomy
consist of injuries to the heart or great vessels and
tracheal, bronchial, or esophageal injuries.
Diaphragmatic repair is usually performed via an
abdominal approach.
MANAGEMENT OF ANESTHESIA
Before induction of general anesthesia for trauma
patients undergoing emergency thoracotomy, it is
critical to exclude the presence of a pneumothorax that
could become a tension pneumothorax with the
institution of mechanical ventilation of the patient's
lungs.
Management of these patients often includes an intra
arterial and central venous pressure catheter, as well
as peripheral large-bore intravenous catheters placed
above the diaphragm. Because of the presence of
lung injury, these patients' lungs need to be
ventilated with low tidal volume ventilation (6 mL/kg
ideal body weight) and a small amount of positive
end-expiratory pressure.
Placement of a double-lumen endotracheal tube to
perform one-lung ventilation may be warranted for lung
resection or repair of the esophagus or large intra
thoracic vessels. These patients are usually
transferred to the Icu with the trachea intubated and
the lungs mechanically ventilated.
ABDOMINAL INJURY
Abdominal injury accounts for a small, but significant
number of trauma-related deaths, especially when the
abdominal injury is not recognized. One of the major
reasons for a fatal outcome is that the peritoneal cavity
and retroperitoneal space are potential reservoirs for
large and occult blood loss.
During initial evaluation of the trauma victim, peritoneal
signs of abdominal trauma are often subtle and
difficult to diagnose because of the intense pain
associated with extra-abdominal injuries or
because of the presence of TBl and altered mental
status.
Thus, during the initial evaluation of a severely
traumatized patient, the first step is to diagnose the
presence of abdominal trauma.
Classification
Traumatic abdominal injuries are classified as
penetrating or blunt injuries. Penetrating injuries
associated with overt signs of peritoneal irritation or
acute blood loss (or both) are clear indications for
surgery.
If there is no violation of the peritoneum, local
exploration is usually sufficient. Blunt trauma is
generally caused by collisions or falls. The severity of
the injury is determined by the accelerationdeceleration process sustained by the victim.
The organs most commonly injured are the liver,
spleen, and kidneys.
Diagnosis
Ultrasound performed in the emergency department is
an important diagnostic tool for detecting the presence
of an abdominal injury, including the presence of blood
in the abdomen. Diagnostic peritoneal lavage (DPL) is a
sensitive method for detecting the presence of serious
intra-abdominal bleeding.
The classic indication for DPL is suspicion of intraabdominal bleeding associated with arterial
hypotension. In stable patients, an abdominal
CT scan with radiocontrast is often performed instead of
DPL. A CT scan allows the clinician to detect the
location and magnitude of intra-abdominal injuries in
hemodynamically stable patients.
CT may also be important for investigating genitourinary
injuries when intravenous radiocontrast is used.
Management of Anesthesia
Severe abdominal injuries require general anesthesia
and often placement of an intra-arterial and central
venous pressure catheter. In many institutions, a
large-bore catheter is placed in a femoral vein on
arrival at the emergency department..
It is important to recognize that the femoral venous
catheter should not be used for rapid blood
transfusions when abdominal venous injuries are
suspected.
It is good practice to place an additional large-bore
catheter above the diaphragm for rapid intravenous
administration of volume to these patients
PELVIC FRACTURES
Pelvic fractures are the third most frequent injury in
victims of motor vehicle accidents and are often
associated with other abdominal injuries. The overall
mortality from pelvic fractures is between 15% and
50%, depending on the extent of the injuries. The
combination of pelvic fracture and severe TBI has
high mortality..
The initial treatment of pelvic fractures associated with
bleeding is nonoperative, and they are managed by
angiographic embolization.
In addition to this treatment, patients may require
external fixation of the fractures to allow mobilization.
Alternatively, stabilization of the pelvis can be
achieved with the use of military antishock trousers
(MAST).
The anesthesiologist has a critical role to play during
the initial resuscitation of patients with severe pelvic
fractures.
These patients frequently require the administration
of large volumes of blood, thus necessitating activation
of the massive transfusion protocol. As with other
abdominal injuries, it is also imperative to place largebore intravenous catheters above the diaphragm.
BLUNT SPLENIC AND LIVER INJURIES
There has been a change in the management of blunt
splenic and liver injuries toward a more conservative
approach. Patients without signs of hemodynamic
instability or intra-abdominal bleeding can be
monitored closely in the ICU after the initial
evaluation and placement of large-bore intravenous
catheters.
Usually, it is mandatory to obtain sequential hematocrit
measurements during the first 24 hours and to
frequently examine these patients for detection of any
signs of new intra-abdominal bleeding.
Furthermore, these patients are at risk for abdominal
compartment syndrome because of the increased
vascular permeability associated with severe trauma.
Thermal (Burn ) injury
Continuous improvement in the care of burned patients
for the last 30 years has resulted in an increase in
survival after the initial insult. It is not uncommon to
see patients with burns affecting 70% to 80% of the
total body surface area to survive this injury.
Critical factors that affect mortality in these patients
include age older than 60 years, third-degree burns
over more than 40% of the total body surface area,
and smoke inhalation. Mortality increases in
proportion to the number of risk factors present. In
addition, the mortality rate of burned patients is also
affected by the presence of significant coexisting
diseases and delays in treatment.
Initial Evaluation
The initial clinical evaluation of an acutely burned
patient includes a careful analysis of the burned body
surface area, the depth of the burns, the mechanisms
of injury (electrical, smoke inhalation), and the
presence of associated traumatic injuries .
Furthermore, information should be obtained as soon
as possible about the presence of significant
comorbid conditions that may affect the survival of a
severely burned patient.
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Initial Fluid Resuscitation
The initial treatment of burned patients includes an
assessment of the fluid resuscitation requirements for
the first 24 hours. The most commonly used guideline
for calculation of fluid replacement needs is the
Parkland formula (4 mL/kg/% burn); the replacement
fluid is given as lactated Ringer's solution. Half the
volume should be given during the first 8 hours and
the other half during the following 16 hours.
After the first 24 hours, protein repletion is frequently
needed and is typically provided by 5% albumin (0.3
to 0.5 mL/kg/total body surface area of burned
tissue). In addition to colloid replacement, a
burned patient should receive maintenance fluid, which
can be estimated as basal maintenance (1500 mL/m2
+evaporative water loss [(25 + % burn) x m2 x 24]).
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Clinical evidence of adequate fluid resuscitation
includes normalization of systemic blood pressure,
urine output (> 1 mL/kg/hr), and values for blood
lactate, base deficit,plasma sodium concentration,
and central venous pressure
Urine output is not a reliable guide to the adequacy of
resuscitation after the first 24 to 48 hours following a
burn injury because of the presence of osmotic diuresis
associated with glucose intolerance and high caloric
feeding.
Furthermore, a non-anion gap arterial base deficit may
reflect the excessive intravenous administration of 0.9%
sodium chloride solution.
In elderly patients or those with significant preexisting
cardiac disease, hemodynamic parameters should be
monitored carefully, possibly with placement of a
pulmonary artery catheter, to prevent the
development of acute congestive heart failure as a
result of vigorous fluid resuscitation. Rapid fluid
resuscitation can be associated with the development
of severe tissue edema compromising limb perfusion
or an abdominal compartment syndrome.
Management of Anesthesia
Burned patients will require general anesthesia, initially
for escharotomy of the limbs, thorax, and/or abdomen
and later for excision of the burned skin and grafting.
If the injuries do not preclude conventional airway
management, standard anesthesia induction and
tracheal intubation procedures are appropriate.
However, succinylcholine should not be administered
when the burn injury is older than 24 hours because
drug-induced hyperkalemia may result in cardiac
arrest. The trachea of a severely burned patient
should remain intubated after the initial
escharotomies because the aggressive fluid
management that occurs during the following 24 to
48 hours to compensate for the burn shock often
causes airway edema and compromise.
The patient's lungs should be ventilated with low-tidal
volume ventilation (6 mL/kg ideal body weight)
if smoke inhalation injury or acute lung injury from
another origin is present. Placement of an intraarterial and central venous catheter should be done
under sterile conditions.
.
Particular attention should be paid to the impaired
temperature regulation associated with severe burns.
Excision of burned skin is accompanied by substantial
blood loss, which can be estimated at 0.5 mL/cm2 of
burned area
At the conclusion of surgery, transport of severely
burned patients to the ICU should be planned carefully
because accidental extubation during the transport of
these patients may result in an inability to ventilate the
patient's lungs by mask because of face and neck
burns.
Lean body weight or mass
Ideal Body Weight (men) = 50 + 2.3 ( Height(in) - 60 ) (
Devine formula)
Ideal Body Weight (women) = 45.5 + 2.3 ( Height(in) 60 ) (Robinson formula)
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Lean body weight or mass
Ideal Body Weight (men) = 50 + 2.3 ( Height(in) - 60 ) (
Devine formula)
Ideal Body Weight (women) = 45.5 + 2.3 ( Height(in) 60 ) (Robinson formula)
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