Michael Parr, director of Liverpool ICU in Australia, speaks about "Surviving Trauma Guidelines". He does so through the use of an interesting case of a patient admitted to ICU following a MVA. This educational podcast was recorded at BCC4.

1. ICU-Surviving Trauma Guidelines

6. Brain trauma foundation

7. Levels of evidence
Class 1: Things I believe
Class 1 : Things I believe despite the data
Class 1: Randomised controlled clinical trials that agree
with what I believe
Class 2: Expert opinion that agrees with me
Class 3: Other data that agrees with me
Class 4: Randomised controlled clinical trials that don't
agree with what I believe
Class 5: What you believe and I do not

8. Prehospital
• M -28 yo female, high speed MVC
• I -abdominal tenderness, seatbelt
bruise, difficulty breathing and
talking, pregnant 32/40
• S -HR 166 BP 75/- RR 38 GCS 14
• T -250ml Hartmanns

9. ED Primary Survey
• A -One word replies, c-collar on
• B -RR 40 ?decreased BS left chest, SaO290%
• C -HR 124 BP 105/65, wedge under right side
• D -GCS 14
• FAST - free fluid, seatbelt bruise, tender abdomen
• Left ankle #
• Off spine board, spinal exam and PR
• CXR done
What Now?

11. Plan for OT
• Pale, gasping
• Intubated T+13 min
• T+14 min: difficulty ventilating
• Decreased BS L and R chest
• Bilateral chest tubes T+ 20 min

12. OT (+30min)
• Laparotomy
• Ruptured uterus: intra-abdominal foetus-
deceased
• Hysterectomy
• Ruptured left hemidiaphragm -sutured
• Bowel NAD
• Retroperitoneal structures NAD
• Liver and spleen NAD
• Contused and collapsed left lower lobe
• No haemopericardium

14. Surgery terminated at 1 hour
• Damage Control
• Packs to pelvis and to left upper quadrant
• Temporary abdominal closure
• 7 PRBCs, 4 FFP, 1 pooled platelets
ICU
• HR120, BP 100/76
• pH 6.95 PaCO2 62 PaO2 203, HCO3
- 16, BE -10, lactate 5.8
• Temp 35ºC
• HB 90, Plts 98,
• PT 15.7 (10.5-13.5), APTT 39(25-37), INR 1.4, fibrinogen 1.90
(2-4.3)

15. What Now?

17. Role for ICU
• Optimisation of systems:
Haemodynamics, oxygenation/ventilation,
renal function, nutrition
• Correct hypothermia, coagulopathy and
acidosis (the TRIAD)
• Monitoring –BP, IAP, ScvO2, UO

18. Rules of Intensive Care
• Assume nothing
• Trust no one
• Give oxygen (enough, not too much)
• History (PMH and medications)
• Examination
• ALL investigations and imaging

19. Resuscitation Endpoints
EAST: Level 1
• Standard hemodynamic parameters do not adequately
quantify the degree of physiologic derangement in
trauma patients.
• Base deficit, lactate level, should be used to stratify
patients with regard to the need for ongoing fluid
resuscitation, including PRBCs and other blood
products, and the risks of MODS and death.
• Oxygen delivery parameters: ability of a patient to attain
supranormal correlates with an improved chance for
survival relative to patients who cannot achieve these
parameters.

20. Balogh, Z et al. Abdominal Compartment Syndrome: The
Cause or Effect of Postinjury Multiple Organ Failure. Shock
2003;20:483-492
• Patients have a pulmonary artery catheter and gastric
tonometer placed and are resuscitated according to a
protocol to achieve a specified oxygen delivery index
(DO2I) goal for 24 h.
• Interventions:
– 1) PRBC transfusions if Hb <10 g/dL,
– 2) crystalloid boluses to increase PCWP >=15 mmHg if DO2I <
goal
– 3) Starling curve generation with successive 500 mL crystalloid
boluses to optimize CI-PCWP relationship if Hb >=10
g/dL, PCWP >=15 mmHg, and DO2I < goal
– 4) inotrope if CI-PCWP has been optimized and DO2I < goal
– 5) vasopressor if mean arterial pressure <65 mmHg

21. – At the inception of the protocol, DO2I >= 600
mL/min/m2 was the goal of the protocol process.
This goal was chosen by review of the published
literature and local consensus opinion.
– After 2 years, based on consensus groups
concerns over the large volume of crystalloid
being administered (13 litres in 24 hours) and
publication of the most recent trial by Shoemaker
and colleagues which failed to demonstrate
improvement in survival in trauma patients with a
similar protocol process with a DO2 >= 600
goal, we decreased the DO2I goal in patients to
500 mL/min/m2

23. What fluid?
How much?

24. Transfusion Guideline
• In patients hemodynamically unstable as defined by:
• SBP ≤ 90 mmHg or
• SBP is only maintained > 90 mmHg with massive fluids or vasopressor
support
• RBC should be administered as determined by "clinical necessity".
• In patients hemodynamically stable as defined by:
• No SBP≤ 90 mmHg for 1 hour and
• No resuscitation (or use of vasopressor support) (exception: use of low
dose vasopressor support for neurogenic shock)
• Hemoglobin < 7g/dL: RBC justified
• Hemoglobin 7-9 g/dL: RBC if evidence of hypoperfusion is present
• Hemoglobin > 9 g/dL: No RBC transfusions

25. Ventilation weaning
Patients requiring mechanical ventilation will be ventilated to achieve:
• Decreasing FiO2 (and PEEP) as early as possible.
• Limiting ventilation volumes to no greater than 6+/-2 ml/kg predicted
body weight as much as possible
• Limiting plateau pressures to ≤ 30 cm H20 whenever possible
• Avoiding the use of muscle relaxants.
• Attempting to wean on an ongoing basis.
Ventilation with lower tidal volumes as compared with traditional tidal volumes
for acute lung injury and the acute respiratory distress syndrome. The Acute
Respiratory Distress Syndrome Network. N Engl J Med. 2000; 342: 1301-
1308.

26. Time to re-evaluate
• Vital signs
• Clinical examination
• Blood loss
• Urine output
• Repeat ABG (lactate and BD), FBC and
coagulation

27. RAPTOR
Resuscitation with Angiography, Percutaneous Techniques and Operative Repair

33. Clinical examination is an inaccurate predictor of intra-abdominal pressure.
World Journal of Surgery 2002;26:1428-1431.

35. Intra-abdominal hypertension and
abdominal compartment syndrome
• An objective assessment of IAP is required
• IAP can be estimated from the transduced pressure of
an indwelling urinary catheter
• A pressure >30 mmHg confirms ACS and requires return
to OR for initial or further decompression.

36. Strategies to correct coagulopathy
• Still bleeding?
• Intracerebral bleed?
• Guided vs empiric
• Repeat tests and modify treatment
accordingly
• The patient is going to be prothrombotic in 24
hours!
• Start physical VTE prophylaxis

37. Role for ICU
• Diagnose all injuries
• Prevention of complications
• Infection control- remove dirty lines
• Make a comprehensive plan
– Factor in previous co-morbidities
• Discussion with patient / family

38. Traumatic rupture of aorta
Diaphragmatic rupture
Bowel injury
Fractures / ligament damage
Nerve injury

39. A patient at risk??

40. Cervical Spine Injuries Following Trauma
Obtunded patient with a negative CT and gross motor function of all four
extremities:
• F/E radiography should not be performed (level 2).
• The risk/benefit ratio of obtaining MRI in addition to CT is not clear, and its
use must be individualized in each institution (level 3).
Options are as follows:
A. Continue cervical collar immobilization until a clinical examination can be
performed.
B. Remove the cervical collar on the basis of CT alone.
C. Obtain MRI.
3. If MRI disclosed nothing abnormal, the cervical collar may be safely
removed (level 2).

41. Cervical Spine Injuries Following Trauma
Obtunded patient with a negative CT and gross motor function of all four
extremities:
• F/E radiography should not be performed (level 2).
• The risk/benefit ratio of obtaining MRI in addition to CT is not clear, and its
use must be individualized in each institution (level 3).
Options are as follows:
A. Continue cervical collar immobilization until a clinical examination can be
performed.
Remove the cervical collar on the basis of CT alone.
C. Obtain MRI.
3. If MRI disclosed nothing abnormal, the cervical collar may be safely
removed (level 2).

42. Prevent further complications
• Mouth care
• Feeding
• Analgesia
• Sedation
• Thrombo-prophylaxis
• Head of bed elevated
• Ulcer prophylaxis
• Glucose management
• Damage control strategies
• Ventilation weaning (use sedation and pain scoring)
• Blood product guidelines
• Tertiary survey

45. Further progress ICU
• Right chest drain 285ml output
• Left chest drain output 2800ml ?chyle
• Patient not haemodynamically unstable
• Diaphragmatic repair was inspected at
definitive closure - intact and sound