Critical Care of the Multiple-Injured Pt
Introduction
Reassessment
Chart Review
Investigations and Plans
Head Injury
Surgical Treatment
Introduction

Remember the third peak of trauma deaths - in ICU days or weeks later.
- usually of sepsis or multi-organ failure
- often because initial resuscitation / management was inadequate or delayed.

Initial Care
Is discussed in trauma notes
Pts may then be admitted either:
- stable (unforseen major problems rare but possible)
- requiring surgical intervention (in danger, may have undetected problems and require ongoing MDT care)
- under-resuscitate or under-investigated inadvertently.
- In poor condition for unknown reasons, admitted for observation
Reassessing the Pt

It is important to identify pts at risk to end up in higher-dependency units.
- pts must not be 'left to others' until they are stable.
--> when dealing with the multiply-injured, raise your level of suspicion, and improve your management skills.

Reassessment
Recognise that trauma is dynamic and requires ongoing re-evaluation.
- repeat the primary survey during transfer to ward / HDU
--> if the pt is not stable, urgent intervention is required
- reassess effect of earlier interventions, eg response to fluids, recheck Hb
- check site of airways, chest drains, delivery of high-flow O2 etc.
- ensure urine output satisfactory (eg 50ml/hr is usually adequate)
- if stable, perform full secondary survey, including abdo and pelvis
--> do not miss compartment syndrome.
- review history of events: this may help yield missed injuries.
- consider further investigations, form a definitive plan
--> remember viscera eg bowel / GB may rupture several days down the line.

Remember to act on positive signs, and re-evaluate negative signs.
--> summon help if you suspect a previously undetected abdo injury, or there is unexplained hypotension.
--> follow all lines, catheters, tubes etc closely, checking position and for infection (this is a medical, not a nursing responsibility).
Chart Review

Regularly review all recorded data.
- look regularly at resp function data
- remember hypotension is a late sign, think perfusion.

Follow available results
- remember Hb is no marker of bleeding or resuscitation
- WCC will be raised, but sudden rises or falls should be suspicious
- consider coags after massive transfusion
- U&Es, ABG, ECG, XRs as required.

Review Drug Chart
- don't forget tetanus status
- treat open #s with cephalosporins
- remember DVT prophylaxis
- follow-up on regularly drug needs
Investigations and Plans

It is usually up to the surgical registrar to undertake plans daily.
- prescribe fluids, O2, blood products etc daily.
- maintain an accurate input/output chart
- consider a nutrition plan early
- arrange physio early, particularly chest, but also for injured parts
- liaise with other MDT team members re treatments.

Investigated the unstable or deteriorating pt.
- treat acute complications rapidly
- bronchoscopy, echo, FAST, CT, DPL, IVU may be required.
--> remember never to send an unstable pt to radiology
Head Injuries

Often best-managed in ICU
- undertake head CT when indicated by ATLS guidelines. 

Cerebral Perfusion
CPP=MAP-ICP
- the two aims are to preserve CPP and reduce ICP
--> want CPP>70 and ICP<25
--> this is prognostically important

Ways to Reduce ICP
- nursing the pt 30o head up
- avoid neck-compression (eg sandbacks and collar on but undone for ?neck injuries)
- sedation and paralysis (reduces straining etc)
- avoid pyrexia
- ventilate to keep PCO2 low-normal
- mannitol and frusemide (involve neurosurgery for these decisions)
- barbiturates and corticosteroids are being trialled
- external ventricular drainage
- surgical decompression
Surgical Treatment

Time aggressive surgical intervention as early as possible.
- these pts cannot be 'stabilised' before going to theatre
Conservative management or liver/spleen injuries is consultant-only.
'Damage-control' surgery is a new concept of minimal effective intervention to get them through the danger period, used in shocked perhaps-coagulopathic pts.

Thoracotomy in A&E
Is indicated only for pts with penetrating thoracic injury who arrest in hospital or who will not survive to reach theatre.
- this will not work in blunt trauma
- clamping the aorta or internal heart massage may assist the pt exsanguinating from their abdomen.
- manage skeletal injuries early.

Abdominal Comparment Syndrome
See card